Antithymocyte globulin and cyclosporin in children with acquired aplastic anemia

OBJECTIVE

To assess the responses to ATG and cyclosporin combination in patients of aplastic anemia.

METHODS

Twenty three (17M: 6F) patients of aplastic anemia (11 very severe aplastic anemia (VSAA) and 12 severe aplastic anemia (SAA), were administered antithymocyte globulin and cyclosporin.

RESULTS

The median age of patents was 8 years (range 6-12 years). Three patients died within 2 months of therapy. Twenty children (11 SAA and 9 VSAA) were finally analysed. Six months after the start of treatment, 8/20 (40%) patients responded-2 complete (CR) and 6 partial responses (PR). At the end of 1 year; 2 patients maintained CR and seven patients continued PR (overall responders 45%). The response was better in SAA (54.5%) with 2 CR and 4 PR; than in VSAA (33%) with 3 PR . Eleven (55%) children were alive without response. One patient developed AML 13 months later.

CONCLUSION

We conclude that antithymocyte globulin and cyclosporin combination is an effective treatment for aplastic anemia patients who are ineligible for bone marrow transplantation.

Case control study of psychosocial morbidity in beta thalassemia major

OBJECTIVES

To assess the prevalence and the spectrum of psychosocial morbidity and its correlation with various social and disease-related factors in children with beta thalassemia major.

STUDY DESIGN

Sixty children with transfusion-dependent beta thalassemia major were included in the study group who fulfilled these inclusion criteria: 1) age 5 to 15 years; 2) both parents alive and living together; 3) negative for human immunodeficiency virus; and 4) no family history of any chronic illness or psychological illness. The control group consisted of 60 children of matched age group and social background. A semi-structured interview and 2 preformed questionnaires (Pediatric Symptom Checklist [PSC] and Childhood Psychopathology Measurement Schedule [CPMS]) were used to assess psychosocial morbidity.

RESULTS

The mean score of the PSC was 11.63 +/- 3.79 (range, 7-24) in children with thalassemia, compared with 5.78 +/- 2.572 (range, 2-13) in the control group (P < .001). The mean score of the CPMS was 11.63 +/- 3.6 (range, 6-25) compared with 6.08 +/- 2.8 (range, 1-14) in the study and the control group, respectively (P < .001). Among the children with thalassemia, 54% had a mean CPMS score > or = 10 (which is considered significant for psychopathological disorders), compared with 8.3% in the control group (P < .001).

CONCLUSION

Children with thalassemia have significantly higher psychosocial morbidity. Psychosocial aspects need to be addressed in the overall treatment of children with thalassemia to prevent the development of clinically manifest psychological disease.

Meningococcal disease--outbreak in Delhi

Meningococcal disease occurs both endemically and epidemically across the world. In India also meningococcal disease occurs sporadically with epidemics occurring at regular intervals. Epidemics of meningococcal disease have occurred in Delhi in the year 1935, then in the year 1966 which lasted for a year and again in 1985-86. The last epidemic took a great toll with case fatality rate nearly 13%. This year also there has been an outbreak of meningococcal disease with nearly 400 cases and case fatality rates of about 10% majority are males between the age group of 21-30 years and from the inner crowded areas of the city.

PSYCHIATRIC MORBIDITY IN CHILDREN WITH CHRONIC MEDICAL ILLNESS: A CROSS SECTIONAL STUDY IN KALAWATI SARAN CHILDREN’S HOSPITAL, NEW DELHI

Psychiatric morbidity is common in the medically ill children, although it is frequently unrecognized anduntreated. This study was conducted to determine the nature and extent of psychiatric morbidity in childrenwith chronic medical diseases. 100 children attending the different follow-up clinics at a tertiary carepediatric referral Centre were evaluated using Childhood Psychopathology Measurement Schedule (Malhotraet.el.1988). Thirty one percent children showed abnormally high levels of emotional and behavioral problemsindicative of a possible psychiatric disorder. Attendance at Pediatric OPD was associated with an increasedrisk of common type of childhood psychiatric problems with about 21% children scored abnormally high infactor III (Anxiety) & VII (Physical illness with Emotional problems) suggestive of a definitive psychologicaldisorder. The result indicates that about 1/3 rd children attending pediatric follow-up clinics with chronicmedical illness need a formal psychiatric evaluation for certain psychological disturbances. This also advocatesthe provision of a hospital based pediatric psychiatric liaison service that would help to address this needand create opportunities for pediatricians to train in child psychiatry.Key Words: Psychiatric morbidity; children; chronic medical illness.

Changing perspectives in Japanese encephalitis in India

Japanese encephalitis is a serious public health problem with significant mortality in children and old people. It occurs throughout much of Asia (43 000 cases worldwide per year). In recent years it has caused many epidemics in different parts of the country. In view of the high mortality and severe sequelae which often leaves behind highly dependent and disabled survivors, the disease is assuming great importance. A review of the pathogenesis, epidemiology, management and prevention together with changing perspectives in all these areas is presented.

Comparison of computed radiography and film/screen combination using a contrast-detail phantom

The purpose of this work is to compare computed radiography (Kodak CR 400) and film/screen combination (Speed 400) systems in regards of patient dose, technique settings, and contrast-detail detectability. A special contrast-detail phantom with drilled holes of varying diameter (detail) and varying depth (contrast) was utilized. Various thicknesses of the Lucite sheets were utilized to simulate scattering tissues. Images of the phantom were acquired using a range of 60-120 kVp for film/screen and CR with a conventional x-ray tube and then for CR with additional 2 mm aluminum added filtration to the x-ray beam. The patient entrance skin dose was measured while maintaining 1.6 o.d. for film/screen images and 1900 Exposure Index for CR images. CR phantom images were displayed on the diagnostic workstation for soft copy reading as well as printed on films for hard copy reading on viewbox. Four physicists evaluated the images by scoring the threshold target depth along the row of the same target diameter. Detection ratio was calculated by counting the number of detectable targets divided by the total number of targets in the phantom. The overall score was related to the patient entrance skin dose, kVp, and the thickness of the scattering material. The patient entrance skin dose was reduced as the additional aluminum filter was added to the x-ray beam. Our findings suggested using a higher kVp setting and additional added filtration would reduce the patient entrance skin dose without compromising the contrast-detail detectability, which was compensated by the contrast manipulation on soft-copy display workstations.

Congenital diaphragmatic hernia: delayed presentation with asymptomatic spleenic herniation

Patients with congenital diaphragmatic hernia (CDH) usually present in the immediate neonatal period with respiratory distress. Presentation beyond the neonatal period has, however, been reported. We report a case of a 3-year-old child who presented with a six months history of respiratory symptoms and had been subjected to a variety of therapies like antibiotics, antitubercular medication and two attempts at putting an intercostal tube, as radiographs were suggestive of pleural effusion. This study highlights the importance of a high index of suspicion, relevance of thorough clinical examination and non-invasive diagnostic modalities along with an uncommon occurrence of asymptomatic spleenic herniation at such a later age. Spleenic herniation is rare outside neonatal period.

Rational design and synthesis of novel 2,5-disubstituted cis- and trans-piperidine derivatives exhibiting differential activity for the dopamine transporter

Herein, we report the rational design and synthesis of novel 2,5-disubstituted piperidine derivatives in the cis and trans isomeric forms. Out of these two isomers, the cis-isomer, 7a, was found to exhibit the most potent activity and selectivity for the dopamine transporter. These novel derivatives represent conformationally constrained version of piperidine analogue of GBR compounds.

Typhoid vaccines

Typhoid fever continues to be a major public health problem in developing countries with about 33 million cases per year. Protective efficacy of traditional acetone/phenol killed vaccines is similar to newer typhoid vaccines (Ty21A and Vi antigen vaccine) but side effects of these newer vaccines are considerably less. Though the mortality is low, typhoid fever causes considerable morbidity and loss of working days. Problems during treatment are increasing due to emergence and spread of multidrug resistant S. typhi. Hence to decrease the incidence of typhoid fever in addition to ensuring safe water supply and excreta disposal a typhoid vaccine needs to be introduced in the National Immunization Schedule.

Rational antibiotics therapy in bacterial meningitis

Acute bacterial meningitis is one of the most important causes of morbidity and mortality in developing countries. Though a wide range of antibiotics is available for therapy, judicious and rational use of antimicrobial agents needs to be ascertained. The choice of antimicrobial agents depends mainly on the age of the patient and its CSF penetrability. Neonatal meningitis is commonly caused by Gram Negative organisms such E. coli, Klebsiella and Pseudomans;Group B streptococciand Listeria, though other organisms like Staphylococcus sp. also contribute. The neonatal meningitis is best treated with a combination of amplicillin and a third generation cephalosporin given for 14-21 days. Post-neonatal meningitis usually occurs due to S. pneumoniae, N. meningitidis and H. influenzae and is best treated with third generation cephalosporins used with or without crystalline penicillin or ampicillin depending on the clinical situation. The therapy should be modified, if necessary, on availability of culture sensitivity report. The use of dexamethasone in meningitis due to the organisms other than H. influenzae still remains controversial.

Dual incorporation of photoaffinity ligands on dopamine transporters implicates proximity of labeled domains

We have recently developed novel high-affinity blockers for the dopamine transporter (DAT) by carrying out structure-activity studies of GBR 12909 molecule piperidine analogs. To investigate the molecular basis of binding of these compounds in comparison to known sites of action of GBR 12909, cocaine, and benztropine analogs, we developed a piperidine-based photoaffinity label [(125)I]4-[2-(diphenylmethoxy)ethyl]-1-[(4-azido- 3-iodophenyl)methyl]-piperidine [(125)I]AD-96-129), and used proteolysis and epitope-specific immunoprecipitation to identify the protein domains that interact with the ligand. [(125)I]AD-96-129 became incorporated into two different regions of the DAT primary sequence, an N-terminal site containing transmembrane domains (TMs) 1 to 2, and a second site containing TMs 4 to 6. Both of these regions have been identified previously as sites involved in the binding of other DAT photoaffinity labels. However, in contrast to the previously characterized ligands that showed nearly complete specificity in their binding site incorporation, [(125)I]AD-96-129 became incorporated into both sites at comparable levels. These results suggest that the two domains may be in close three-dimensional proximity and contribute to binding of multiple uptake blockers. We also found that DATs labeled with [(125)I]AD-96-129 or other photoaffinity labels displayed distinctive sensitivities to proteolysis of a site in the second extracellular loop, with protease resistance related to the extent of ligand incorporation in the TM4 to 6 region. These differences in protease sensitivity may indicate the relative proximity of the ligands to the protease site or reflect antagonist-induced conformational changes in the loop related to transport inhibition.

Structure-activity relationship studies of 4-[2-(diphenylmethoxy)ethyl]-1-benzylpiperidine derivatives and their N-analogues: evaluation of O-and N-analogues and their binding to monoamine transporters

In our effort to develop a pharmacotherapy for the treatment of cocaine addiction, we embarked on synthesizing novel molecules targeting the dopamine transporter (DAT) molecule in the brain as DAT has been implicated strongly in the reinforcing effect of cocaine. Our previously developed DAT-selective piperidine analogue, 4-[2-(diphenylmethoxy)ethyl]-1-benzylpiperidine, was the basis for our current structure-activity relationship (SAR) studies exploring the significance of the contribution of the benzhydryl O- and N-atoms in these molecules in interacting with the DAT. Thus, we replaced the benzhydryl O-atom with an N-atom, altered the location of the benzhydryl N-atom to an adjacent position, and in one other occasion converted the benzhydryl O-ether linkage into an oxime-type derivative. Furthermore, we also evaluated the important contribution of the piperidine N-atom to binding by altering its pK(a) value chemically. Novel analogues were tested for potency in inhibiting [3H]WIN 35,428, [3H]citalopram, and [3H]nisoxetine binding at the DAT, serotonin transporter (SERT), and norepinepherine transporter (NET). [3H]DA was used to measure DA reuptake inhibition. The results indicated that the benzhydryl O- and N-atoms are exchangeable for the most part. On the other hand, an enhanced interaction with the SERT was observed when the benzhydryl N-atom moved to an adjacent position (21a; DAT (IC(50)) = 19.7, SERT (IC(50)) = 137 nM, NET (IC(50)) = 1111 nM). In either cases, further alkylation of the N-atom reduced the activity for the transporter. The presence of a powerful electron-withdrawing cyano group in compound 5d expectedly produced the most potent and selective ligand for the DAT (DAT (IC(50)) = 3.7 nM, DAT/SERT = 615). Selected compounds were further analyzed in the dopamine reuptake inhibition assay. Preliminary behavioral assessment of some of the selected compounds in mice indicated that these compounds are much less stimulating when compared with cocaine at comparable doses. In drug-discrimination studies these selected compounds incompletely generalized from the cocaine stimulus in mice trained to discriminate 10 mg/kg cocaine from vehicle.

Design, synthesis, and characterization of a novel, 4-[2-(diphenylmethoxy)ethyl]-1-benzyl piperidine-based, dopamine transporter photoaffinity label

The dopamine transporter (DAT) has been implicated strongly in cocaine's reinforcing effects. Many derivatives of piperidine analogs of GBR 12909 have been developed and were found to be quite potent and selective for the DAT. In this regard, most of these derivatives were found to be much more selective for the DAT than conventional GBR compounds e.g. GBR 12909 when their selectivity was compared with the serotonin transporter (SERT). A brief structure-activity relationship (SAR) study has been carried out in the development of a novel photoaffinity ligand which illustrated the effect of the presence of a sterically bulky iodine atom next to the azido group in activity and selectivity for the DAT. This SAR study also led to the development of the compound 4 which is one of the most potent and selective blockers for the DAT known today. The photoaffinity ligand [125I]AD-96-129 was incorporated into the DAT molecule as was demonstrated by immunoprecipitation with serum 16 which is specific for DAT. This photolabeling was antagonized by DAT-specific blockers and was unaffected by specific SERT and norepinephrine transporter (NET) blockers indicating interaction of this novel ligand with the DAT.

Pulmonary function tests in beta thalassemia

To study pulmonary function tests (PFT) in multiple transfusion recipient thalassemics, PFTs were done for 30 thalassemics and 20 matched controls. Confirmed cases of thalassemia on regular transfusion therapy were the subject of study. Apart from history and physical examination of the thalassemics, serum ferritin estimation and spirometry were done. Parameters studied included lung volumes--functional residual capacity (FRC), forced vital capacity (FVC), residual volume (RV) and total lung capacity (TLC); and flow rates--forced expiratory volume in one second (FEV1), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), peak expiratory flow 25-75 (PEF 25-75%) and peak expiratory flow rate (PEFR). Single breath carbon monoxide diffusing capacity (DLco) and arterial blood gas (ABG) were also analysed. The mean height and weight of thalassemics were below that of age matched controls. A restrictive abnormality in PFT was found in 86.6% cases. These patients were found to have a decrease in all the lung volumes namely FVC, FRC, RV and TLC with a proportional decrease in the flow rates, FEV1, PEF 25-75% and PEF with a normal (> 0.75) FEV1/FVC ratio. DLco was decreased in all the patients with restrictive lung disease and fall in DLco showed a good correlation (r = 0.7, P < .001) with the severity of restrictive disease suggesting that some intrapulmonary pathology is likely to be responsible for the restrictive pattern. None of the cases had an obstructive or mixed pattern of pulmonary dysfunction. No correlation was found between severity of restrictive disease and the serum ferritin levels. A negative correlation with degree of hepatosplenomegaly was found. No correlation was found between severity of the defect and age, number of blood transfusions received and hemoglobin at the time of doing the test. To conclude, restrictive lung disease is the predominant abnormality in multi-transfused thalassemics, which is probably due to pulmonary parenchymal pathology. The abnormality of PFTs is not directly related to iron overload.

Synthesis and preliminary characterization of a high-affinity novel radioligand for the dopamine transporter

In our effort to develop a novel radioligand selective for the dopamine transporter, compound 1b (O-972) was designed and characterized. The compound 1b was characterized for its binding both in monkey and rat striatum tissue, which demonstrated its high selectivity for the dopamine transporter (DAT) when its binding was compared with that at the serotonin transporter (SERT). The compound 5, which is a precursor for the tritiated radiolabel ligand [3H]O-972, was synthesized and biologically characterized. The preliminary characterization of this novel radioligand revealed its strong binding affinity for the DAT. Thus, the pharmacological profile of [3H]O-972 indicated that DAT inhibitors, which include GBR 12909, mazindol, CFT, and cocaine, could potently displace this novel radioligand from monkey brain striatum tissue. On the other hand, compounds known to be not selective for and potent at the DAT were very weak to do so. Initial binding results also indicate that [3H]O-972 may interact with the DAT in a manner that is not identical to that for GBR 12909 and tropane analogs.

Diethylene glycol poisoning in Gurgaon, India, 1998

OBJECTIVE

To discover the cause of acute renal failure in 36 children aged 2 months to 6 years who were admitted to two hospitals in Delhi between 1 April and 9 June 1998.

METHODS

Data were collected from hospital records, parents and doctors of the patients, and district health officials. Further information was obtained from house visits and community surveys; blood and stool samples were collected from other ill children, healthy family members and community contacts. Samples of drinking-water and water from a tube-well were tested for coliform organisms.

FINDINGS

Most of the children (26/36) were from the Gurgaon district in Haryana or had visited Gurgaon town for treatment of a minor illness. Acute renal failure developed after an episode of acute febrile illness with or without watery diarrhoea or mild respiratory symptoms for which the children had been treated with unknown medicines by private medical practitioners. On admission to hospital the children were not dehydrated. Median blood urea concentration was 150 mg/dl (range 79-311 mg/dl) and median serum creatinine concentration was 5.6 mg/dl (range 2.6-10.8 mg/dl). Kidney biopsy showed acute tubular necrosis. Thirty-three children were known to have died despite being treated with peritoneal dialysis and supportive therapy.

CONCLUSION

Cough expectorant manufactured by a company in Gurgaon was found to be contaminated with diethylene glycol (17.5% v/v), but a sample of acetaminophen manufactured by the same company tested negative for contamination when gas-liquid chromatography was used. Thus, poisoning with diethylene glycol seems to be the cause of acute renal failure in these children.

Idiopathic pulmonary hemosiderosis

Two cases of idiopathic pulmonary hemosiderosis in children are reported. Both cases presented with a combination of acute/recurrent respiratory symptoms along with iron deficiency anemia. In one case diagnosis was delayed for 18 months after onset of symptoms. After initial stabilisation with corticosteroid therapy, both cases were put on chloroquine therapy and showed improvement. Various other forms of therapy and outcome are discussed. It is suggested that in cases with recurrent respiratory symptoms, idiopathic pulmonary hemosiderosis should also be considered after excluding infectious etiology.

Seroepidemiology of hepatitis A in Delhi

A prospective study was done to determine the age specific prevalence of antihepatitis A antibodies (anti HAV Abs) among children in Delhi. Four hundred and twenty children aged 0-12 years attending outpatient department for vaccination or any minor illness were studied. Sera was tested by ELISA for anti HAV Abs using a commercial kit (Hepvase A 96 TMB). Thirty samples of cord blood were similarly analyzed. All samples of cord blood were positive for anti HAV Abs. Prevalence of anti HAV Abs was 80% by 5 years of age. The most vulnerable age group was 0.5-1.5 years (anti HAV Ab positivity). Cord blood had 100% positivity. Univariate and multivariate analyses taking anti HAV antibody positivity as dependant variable demonstrated that age and father's education (socioeconomic status) significantly affect prevalence of anti HAV Abs. Sex, water supply, history of jaundice in self or family did not have any significant effect on anti HAV antibody positivity. Prevalence of anti HAV antibodies is 80% by 5 years of age. Further studies in different strata of society and different regions in the country are required to assess the need and age for vaccination.

Free oxygen radicals in acute renal failure

OBJECTIVE

To assess the levels of free oxygen radicals in acute renal failure and their predictive value in clinical outcome.

DESIGN

Prospective.

SETTING

Intensive care unit.

METHODS

Study was conducted in 50 children (25 with acute renal failure and 25 age and sex matched controls). Blood urea, serum creatinine, serum protein, uric acid and free oxygen radical markers were estimated in both groups. Superoxide dismutase (SOD), glutathione peroxidase(GPx) and lipid peroxide (LPO) were estimated in blood by standard techniques.

RESULTS

Hemolytic uremic syndrome (HUS) was a major cause of acute renal failure (52%), rest were due to acute glomerulonephritis (AGN), septicemia and renal venous thrombosis. In the renal failure group 56% of the patients were dialyzed (peritoneal) and the mortality was 28% (7/25). The levels of SOD, GPx and LPO were significantly raised in renal failure group. Higher values of LPO, SOD and GPx were documented in subjects who expired. The most important independent variable for predicting clinical outcome was LPO with a sensitivity of 89.4%, specificity of 93%, positive predictive value of 95%.

CONCLUSION

Levels of free oxygen radicals (SOD, LPO and GPx) are raised in acute renal failure and these enzymes can be used as marker of renal injury. LPO levels are highly sensitivity and specific for predicting the clinical outcome

Status of antioxidants and other biochemical abnormalities in children with dengue fever

During an outbreak of dengue fever in 1996, 66 children between 45 days and 12 years of age with dengue fever and 25 healthy controls were studied for antioxidants and other biochemical abnormalities. As per World Health Organization (WHO) criteria, 14 children were classified as having classical dengue (DEN), 42 with dengue haemorrhagic fever (DHF), and 10 (including three who died) as having dengue shock syndrome (DSS). Superoxide dismutase (SOD), glutathione peroxidase (GPX), and albumin (ALB), the three main antioxidants studied, were found to be abnormal in 96, 94, and 40 per cent of the cases respectively. The levels for aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine phosphokinase (CPK), total protein (TP), total cholesterol (CHO), and triglycerides (TGL) were abnormal in 79, 50, 30, 93, and 67 per cent of the cases respectively. Among the different groups of dengue the abnormalities were more marked in children with DSS than in those with DEN and DHF, especially with respect to ALB, TP, TGL, AST, ALT, and CPK (p < 0.005). This preliminary report of dengue confirms the assumption of free radical generation and alteration in antioxidant status during acute illness. However, to understand their complex interaction in disease progression and therapeutic utility, further studies are required.

Tolerance in the replacement of the benzhydrylic O atom in 4-[2-(diphenylmethoxy)ethyl]-1-benzylpiperidine derivatives by an N atom: development of new-generation potent and selective N-analogue molecules for the dopamine transporter

The replacement of the benzhydrylic oxygen atom of our previously developed dopamine transporter (DAT)-specific ligands 4-[2-(diphenylmethoxy)ethyl]-1-[(4-fluorophenyl)methyl]piperidine, 1a, and 4-[2-(bis(4-fluorophenyl)methoxy)ethyl]-1-benzylpiperidine, 1b, by a nitrogen atom resulted in the development of the N-analogues 4-[2-((diphenylmethyl)amino)ethyl]-1-[(4-fluorophenyl)methyl]pi peridi ne, 4a, and 4-[2-((bis(4-fluorophenyl)methyl)amino)ethyl]-1-benzylpiperidine, 4b. Biological evaluation of these compounds in rat striatal tissue and in HEK-293 cells expressing the cloned human transporters demonstrated high potency and selectivity of these compounds for the DAT. Thus the potency of the compound 4a for the DAT was 9.4 and 30 nM in rat striatal tissue and in the cloned transporter cells, and its binding selectivity for the DAT compared to the serotonin transporter (SERT) for these two systems was 62 and 195, respectively. The compound 4b similarly exhibited high potency and selectivity for the DAT. Thus, the replacement of the O atom in 1a,b by an N atom in 4a,b only had small effects on potency and selectivity. In comparison with GBR 12909 [1-[2-(bis(4-fluorophenyl)methoxy)ethyl]-4-(3-phenylpropyl)piperazine ] and WIN 35,428 [3beta-(p-fluorophenyl)-2beta-carbomethoxytropane] binding, these two novel N-analogues were slightly more potent and far more selective for the DAT. Thus, these novel N-analogues represent more polar new-generation piperidine congeners of GBR 12909. They might have useful potential application in developing a pharmacotherapy for cocaine dependence.

An epidemic of dengue hemorrhagic fever and dengue shock syndrome in children in Delhi

OBJECTIVE

To study clinical profiles and outcome of children of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) during 1996 Delhi epidemic.

DESIGN

Retrospective study.

SETTING

Hospital based study.

METHODS

Children hospitalized from September to November 1996 were studied. All patients were diagnosed, managed and monitored according to a standard protocol.

RESULTS

One hundred and thirty four children (80 (60%) males and 54 (40%) females) were studied. Sixty (45%) children were less than 6 years of age of which 12 presented during infancy. There were 92 (67%) cases of DHF and 42 (33%) cases of DSS. Common symptoms were fever (93%), abdominal pain (49%) and vomiting (68%). The commonest hemorrhagic manifestation was hematemesis (39%) followed by epistaxis (36%) and skin bleeds (33%). Hepatomegaly was observed in 97 (72%) cases and splenomegaly in 25 (19%). Serology was positive (IgM hemaglutination antibody titres > 1: 160) for dengue type 2 in 31 (80%) of 39 patients in whom sera was tested during the acute phase of illness. Mortality was 6%. Hematocrit > 40% was observed in only 25 (18%) patients and hence the management protocol was based on clinical signs and symptoms and not on hematocrit.

CONCLUSIONS

A management protocol of DHF/DSS in which fluid therapy is not based on haematocrit values needs to be formulated.

Poisoning in children: Indian scenario

The retrospective data on childhood poisoning from eight regional hospitals in India has been reviewed. The demographic features and types of poisonings encountered have been compared. The analysis of the data indicated that pediatric poisonings constituted 0.23-3.3% of the total poisoning. The mortality ranged from 0.64-11.6% with highest being from Shimla. Accidental poisoning was common involving 50-90% of children below 5 years of age and males outnumbered the females. Suicidal poisoning was seen after 13 years of age and was due to drugs and household chemicals. One of the hospitals in Delhi recorded a very high incidence (66.6%) of drug poisoning in children. The drugs consumed belonged to phenothiazines, antiepileptics and antipyretics. Iron poisoning was seen in younger children. Kerosene was one of the causes of accidental poisoning at all hospitals except Shimla and rural Maharashtra were probably wood charcoal is widely used. Pesticide poisoning was more prevalent in Punjab and West Bengal whereas plant poisoning was very common in Shimla. Significant number of snake envenomation has been recorded from rural Maharashtra. Other less common accidental poisonings in children included alcohol, corrosives, heavy metals, rodenticides, detergents and disinfectants. Thus various regions in the country showed some variation in types and frequency of childhood poisoning which could be attributed to different geographical and socio-economic background.

Free oxygen radicals--predictors of neonatal outcome following perinatal asphyxia

The study was undertaken to evaluate the role of free oxygen radicals in asphyxiated neonates. Thirty term neonates appropriate for gestational age and with severe birth asphyxia (Apgar score of 3 or less at 1 minute of life) formed the study subjects. The levels of superoxide dismutase (SOD), glutathione peroxidase (GPx), creatine phosphokinase (CPK) and lipid peroxidase (LPO) in the CSF of these neonates were estimated between 12 and 48 hrs of life. Enzyme estimation was performed by standard methods and the results were analysed statistically using Multivariate Logistic Regression analysis and non parametric tests namely Kruskal Wallis test and Wilcoxon's rank sum test. Out of the thirty babies, 14 were observed to be neurologically normal, 9 had significant morbidity and 7 died. The SOD levels ranged from 12.4 to 140 units/ml, GPx from 128 to 1933 nmol/min/dl, CPK from 2 to 2098 IU/dl and LPO from 5.4 to 30.8 umol/hr/dl. The SOD and GPx levels had an inverse relationship whereas rise in LPO and CPK levels were directly proportional to the extent of neurological damage and ultimate clinical outcome. CPK levels higher than 140 IU/ml were lethal and associated with 100% mortality whereas all normal neonates had CPK below 37 IU/ml. The levels of antioxidant enzymes can reliably and significantly predict mortality and morbidity whereas level of an enzyme cannot confidently confer normalcy. Hence antioxidant enzyme levels with a cut off value can be a useful marker and serve as a prognostic indicator in times to come.

Determination of the depth of penetration of the alpha subunit of retinal G protein in membranes: a spectroscopic study

This paper reports the fluorescence quenching of the alpha subunit of retinal rod outer segment G protein (Gtalpha) by vesicles of brominated phospholipids. Two different brominated phospholipids with the bromine quencher groups attached at the 6-7 and 9-10 positions in one of the fatty acyl chains have been used to estimate the depth of penetration of the Gtalpha protein in the lipid vesicles using steady-state fluorescence quenching techniques. Our studies provide evidence of the interaction between Gtalpha protein, in its active conformation, with the lipid vesicles mimicking natural membranes. This study demonstrates that in vitro the distance between fluorescent tryptophan site of Gtalpha and the membrane surface is approximately 6.5 A.

Neonatal mechanical ventilation--experience at a level II care centre

One hundred and fifty nine neonates were ventilated over a period of one year of whom 74 (46.54%) survived. This study aims to analyse the indications, complications and outcome of babies requiring mechanical ventilation. The early outcome measures were (i) survival rate with respect to birth weight, gestation and indication of ventilation, and (ii) Complications of assisted ventilation. One hundred and forty seven babies received IPPV and 34 received CPAP. Twenty two out of these 34 required IPPV later. Survival was cent percent on exclusive CPAP mode. HMD was the commonest indication for ventilation followed by Birth asphyxia, Apnea of prematurity, Meconium Aspiration Syndrome and Persistent Pulmonary Hypertension of the New born. Survival rates increased with increasing birth weight and gestational age, changing from 25% for < 1000 gm and 20% for < 28 wks to 53% for > 2500 gms and 50.2% for > 37 wks. Prolonged ventilatory support was needed for HMD (mean 114 hrs) and PPHN (mean 156 hrs). Commonest complication was Sepsis (26%) followed by Pulmonary hemorrhage, Pneumothorax and IVH. Lower success rates in ventilation is due to the poor survival of babies weighing < 1000 gms and those with a gestation of < 28 wks with nosocomial infections as a major complication of assisted ventilation being an additional factor.

Potent and selective ligands for the dopamine transporter (DAT): structure-activity relationship studies of novel 4-[2-(diphenylmethoxy)ethyl]-1-(3-phenylpropyl)piperidine analogues

Molecular structural modifications of 4-[2-(diphenylmethoxy)ethyl]-1-(3-phenylpropyl)piperidine (1a), a dopamine transporter (DAT)-specific ligand, generated several novel analogues. Biological activities of these new molecules for their binding to the DAT and serotonin transporter (SERT) were evaluated in rat striatal membranes. Some of these new analogues were more potent and selective than GBR 12909 when their binding to the DAT relative to SERT was compared. Thus compounds 9 and 19a were among the most potent (IC50 = 6.6 and 6.0 nM, respectively) and selective (DAT/SERT = 33.8 and 30.0, respectively) compounds in this series, and they were more active than GBR 12909 (IC50 = 14 nM, DAT/SERT = 6.1). Introduction of a double bond in the N-propyl side chain of these molecules did not influence their activities to a great extent. Bioisosteric replacement of the aromatic phenyl group by a thiophene moiety produced some of the most potent compounds in this series.

Immune status of full-term small-for-gestational age neonates in India

The immune status of 25 full-term small-for-gestational age neonates was studied and compared with another 25 term appropriate-for-gestational age neonates, who served as controls. It was observed that the term SGA's had an altered immunological profile. The lymphocyte percentage was low. Cellular immunity as assessed by CD4 and CD8 subset of T-cells, and their ratio was deranged. IgG levels were lower in SGA neonates and showed a linear relation with birth weight. IgM and IgA levels were not affected in SGAs. Complement C3 levels were significantly lower in the SGA neonates. The SGAs are allegedly more prone to infections and this deranged immune status could be the underlying explanation for the predisposition.

Immunogenicity and tolerance of H. influenzae type b, tetanus toxoid conjugate vaccine given concurrently or in combination

The present prospective, open, controlled, randomised comparative trial was undertaken to evaluate the sero response and side effects of PRP-T Conjugate Vaccine (ACT-HIB) in infants and children aged 2 months and 16-24 months. Fifty four babies aged 2 months formed group A, 56 children aged 16-24 months formed group B. Groups A and B were further subdivided into two sub groups each destined to receive either PRP-T vaccine in association with DPT vaccine at different sites (I) or PRP-T and DPT both vaccines at the same site mixed in the same syringe (II). Group A received 3 doses at 2, 3 and 4 months of age and group B received one dose between 16-24 months. The Geometric mean titres of Anti PRP antibodies observed in primary immunisation schedule (A) and single dose vaccination schedule (B) were comparable and significantly higher to prevaccination titres. A serum anti PRP level of > 1.0 mcg/ml after immunisation is believed to correlate with long term protection. Ninety-six percent of infants in Group A and 98% in Group B achieved titres > 1.0 mcg/ml. The side effects were minimal, local and were comparable between the study and control groups, suggesting that PRP-T vaccine is highly immunogenic and well tolerated in Indian infants and children.

Synthesis, pharmacology, and molecular modeling of novel 4-alkyloxy indole derivatives related to cannabimimetic aminoalkyl indoles (AAIs)

Several novel 4-alkyloxy-aminoalkyl indole derivatives 3 were synthesized from 4-benzyloxyindole (1). Alkylation of 1 with 4-(2-chloroethyl)morpholine (NaH/HMPA) formed 2. Deprotection using palladium hydroxide on carbon/hydrogen followed by alkylation with the appropriate alkyl bromide gave the target compounds 3b-3j. In the synthesis of 3i and 3j, the appropriate alkyl bromides 13 and 17 were prepared from the commercially available 1-naphthylethyl bromide 9 using the chain lengthening sequences as shown in Scheme 3. In receptor binding assay and in vivo testing, the long chain alkoxy compounds 3g and 3h (Ki = 127 nM) showed affinity for the CB1 receptor which was approximately 16-35-fold less than that of WIN 55,225. However, the pharmacological profile of 3h mimics that of WIN 55,212. An examination of the SAR of these analogues shows that translocating the napthyl group in AAIs from the C-3 position to C-4 via an oxygen (ether linkage) decreases activity which is in contrast to previous findings that a naphthylcarbonyl at C-4 retains activity. The present work points to the importance of the role of a keto group in the interaction with the receptor. Molecular modeling work suggests that, although reasonable superposition of key structural features between delta 9-THC and AAIs can be made, the overlay is not straightforward. The present study also illustrates the difficulty in accommodating AAIs into the cannabinoid pharmacophore and it seems likely that a unique pharmacophore will need to be developed. Only then will the similarities to and differences from the classical cannabinoid pharmacophore be clearly delineated.

Seroconversion following killed polio vaccine in neonates

The study was carried out to evaluate the efficacy of IPV in neonates and to study the additive effect of IPV or OPV at birth on seroconversion with three subsequent doses of OPV. Addition of IPV or OPV at birth to the conventional OPV schedule resulted in significantly higher seroconversion rates than in the controls, who received three doses of OPV. Three doses of IPV beginning from birth resulted in significantly better seroconversion rates than in the control group. Children receiving 3 doses of IPV showed significantly greater seroconversion rates against type III polio virus than those receiving IPV/OPV at birth followed by 3 doses of OPV. The difference in the seroconversion rates against the other virus types was not significant. A significantly greater number of children who received some vaccine at birth (IPV or OPV) were protected against poliomyelitis by 6 weeks age as compared to those who received no immunization at birth. The study recommends that seroconversion rates following three doses of IPV are satisfactory. Addition of IPV or OPV at birth to the conventional schedule markedly increases the seroconversion rates. Immunization can be started at birth to ensure early protection against poliomyelitis.

End tidal carbon dioxide monitoring--its reliability in neonates

End tidal Carbon dioxide monitoring was undertaken prospectively in all Ventilated neonates in our NICU admitted from March 1995 to August 1995 irrespective of the birth weight, gestational age and indication of ventilation. The aim was to determine the correlation between ETCO2 and PaCO2 in various clinical situations. The arterial blood gases were obtained in all ventilated babies with simultaneous and continuous ETCO2 monitoring and were analysed by AVL 995 Hb blood gas analyser. ETCO2 was analysed by side stream technique by Datex Cardiocap II monitor. A total of 152 samples from in-dwelling radial artery catheters were analysed from babies with birth weight from 900 g to 3400 g, gestation age from 28 to 42 wks and were ventilated for various indications like Severe Birth Asphyxia (SBA), Meconium Aspiration Syndrome (MAS), Recurrent Apnoea and Hyaline Membrane Disease (HMD). Statistical analysis was done in 10 groups to see if the ETCO2 correlated with its corresponding PaCO2 value. The study groups comprised three groups based on birth weight being < 1.5-2.5 kg and > 2.5 kg three groups as per the gestational age being 28-31+6 wks, 32-36+6 wks and 37-41+6 wks and four groups as per the need for ventilation being Severe Birth Asphyxia, Meconium Aspiration Syndrome, Apnoea of Prematurity and Hyaline Membrane Disease. Results of the correlation analysis revealed that the correlation coefficient in the study group ranged from 0.55 to 0.96 and was statistically significant in babies > 2.5 kg and 1.5-2.5 kg, in term and preterms 32-36 wks, and in babies with MAS, SBA and Recurrent Apnoea. The correlation coefficient was lowest in babies with HMD, being 0.55. The study showed that ETCO2 correlates closely with PaCO2 in most clinical situations in neonates and we recommend its use in all level III NICUs in ventilated babies.

Highly selective, novel analogs of 4-[2-(diphenylmethoxy)ethyl]- 1-benzylpiperidine for the dopamine transporter: effect of different aromatic substitutions on their affinity and selectivity

Several analogs of the potent and selective dopamine transporter (DAT) ligand 4-[2-(diphenylmethoxy)ethyl]-1-benzylpiperidine, 1a, were prepared and biologically evaluated at the dopamine and serotonin transporter (SERT) sites. Several substituents were introduced in the aromatic rings to evaluate the influences of electronic and steric interactions in their binding to the DAT. All the novel analogs showed preferential interaction at the DAT compared with the SERT. Different aromatic substitutions in the phenyl ring of the N-benzyl part of the molecule played a key role in the selectivity. In general, compounds with strong electron-withdrawing substituents were most active and selective at the DAT. Thus, compounds 5a (R = F) and 11b (R = NO2) were among the most potent (IC50 = 17.2 and 16.4 nM, respectively) and most selective (SERT/DAT = 112 and 108, respectively) and were far more selective than GBR 12909 (SERT/DAT = 6). Bioisosteric replacement of one of the phenyl rings of the diphenylmethoxy moiety by a thiophene ring was tolerated well and produced the most potent compound 13b (IC50 = 13.8 nM) in the series. Our current structure-activity studies of these piperidine analogs resulted in the generation of second generation of GBR-type compounds, and all of these new compounds reported here were more selective than GBR 12909 in interacting with the DAT over the SERT.

Pedunculated digitate papillomatosis around rectum

This is a report on unusual case of proliferation of dermal and epidermal components having finger-like projection around rectum with extension towards natal cleft in a patient suffering from Hansen's infection.

Structure-activity relationship studies of novel 4-[2-[bis(4-fluorophenyl)methoxy]ethyl]-1-(3-phenylpropyl)piperidine analogs: synthesis and biological evaluation at the dopamine and serotonin transporter sites

Several analogs of the potent dopamine (DA) transporter ligand 4-[2-[bis(4-fluorophenyl)-methoxy]ethyl]-1-(3-phenylpropyl)piperidine, 1b, were made and biologically evaluated for their binding at the DA and serotonin (5HT) transporters in rat striatal membranes. Different alkyl chain lengths and substitutions were introduced in these molecules to generate an optimum activity and selectivity for the DA transporter. In general, unsubstituted and fluoro-substituted compounds were the most active and selective for the DA transporter. The compound 4-[2-(diphenylmethoxy)ethyl]-1-benzylpiperidine, 9a, showed high potency and was the most selective for the DA transporter (5HT/DA = 49) in this series of compounds. Some of these novel analogs were found to be more selective in binding at the DA transporter than the original GBR 12909 molecule, 1-[2-]bis(4-fluorophenyl)methoxy]ethyl]-4-(3- phenylpropyl)piperidine.

Timing and dose of BCG vaccination in infants as assessed by postvaccination tuberculin sensitivity

Tuberculosis is an important public health problem in developing countries and BCG plays an important role in preventing serious form of the disease in children. BCG induced tuberculin sensitivity is a quantitative characteristic and has been used to compare vaccine efficacy. The standard dose of BCG vaccine is 0.1mg in 1 ml though manufacturers of certain strains of BCG, i.e., Copenhagen 1331 recommend half dose in infants. There are also varying ideas about the optimum time to vaccinate babies and some studies suggest that late vaccination confers a high degree of protection. This study was carried out to evaluate tuberculin sensitivity and side effects following 0.05 ml and 0.1 ml of BCG at birth and 0.1 ml of BCG at 4-6 weeks of age. Two hundred and thirty eight newborns were vaccinated randomly with 0.05 ml and 0.05 ml and 0.1 ml of BCG vaccine (Copenhagen 1331 strain) containing .69 million culturable particles per ml. One hundred and eight infants 4-6 weeks of age were vaccinated with 0.1 ml of BCG. One hundred and fifty five (44.7%) infants were evaluated by Mantoux test using 1TU PPD RT23 10-12 weeks after vaccination and 105 (30.6%) followed up till 6 months for any side effects. No significant difference in mean tuberculin reaction, tuberculin positivity and mean scar size was observed in groups receiving 0.1 ml at birth or 4-6 weeks of age. However, the group receiving 0.05 ml at birth had a significantly lower mean tuberculin reaction, tuberculin positivity and mean scar size. No locoregional side effects were observed. Hence the present practice of giving 0.1 ml of BCG at birth should be continued.

Hydroalcoholic human placental extract: skin pigmenting activity and gross chemical composition

BACKGROUND

Vitiligo is a pigmentary disorder of the skin of unknown etiology. It is thought to be of autoimmune origin after demonstration of antibody-mediated destruction of melanocytes. Photochemotherapeutic PUVA therapy is widely used in vitiligo with about 33% success. Aqueous or hydroalcoholic extracts of human placenta of ill-defined composition have also been used therapeutically for vitiligo. A hydroalcoholic human placental extract has been developed by us with pigmenting activity based on experimental therapies. Its chemical analysis was the primary objective of this study.

METHODS

For the guinea pig experiment, 20 drops of the extract or vehicle (60% alcohol) as control was topically applied around the nipples covering the areola zones of male immature white guinea pigs (wt. 175-250 g) daily for 60 days with 15 minutes infrared (IR) exposure used for vascular dilatation and enhancement of the absorption of the extract. Standard methods have been followed for all chemical analyses.

RESULTS

The guinea pig experiment showed clear pigmentation and hypertrophy of the experimental nipples to varying degrees. Chemical analysis of the extract revealed the presence of small-molecular-weight proteins/peptides, lipids (including glycosphingolipids), carbohydrates, sialic acids, cholesterol, triglycerides, high density lipoproteins (HDL), and others, including amino acids, nucleotides, carotenes, vitamins, etc.

CONCLUSION

Glycosphingolipids, known modulators of B and T cells, were reported capable of inducing adhesion, spreading, and motility of melanoma. It is present in the extract and, therefore, may lead to skin pigmentation through induction of melanocytes. Endothelin, a 21-amino acid peptide, detected in human placenta and possibly extractable by our process, has been reported to be indispensable for melanocyte growth.