Newer anti-epileptic drugs

During the past few years, a number of drugs have been added to the anti-epileptic arsenal. This review focusses on five of these drugs which have undergone extensive trials: Vigabatrin, Lamotrigine, Gabapentin, Felbamate and Oxcarbazepine. Some of these antiepileptic drugs appear to be helpful for treatment of catastrophic childhood epilepsies. Vigabatrin appears promising in children with infantile spasms who do not respond to ACTH or Prednisolone. Children with Lennox-Gastaut syndrome may respond to treatment with Lamotrigine or Vigabatrin. Gabapentin and vigabatrin have proved to be effective in refractory partial seizures. Oxcarbazepine, a ketoderivative of carbamazepine, is as effective as Carbamazepine but has a better safety profile. Lesser neurotoxicity and fewer drug interactions is another advantage with these drugs. However monitoring is required to determine the long term safety with their usage. These drugs have a definite role in childhood epilepsies refractory to conventional antiepileptic drugs.

Kala-azar: experience from a non-endemic area in India

Resurgence of Kala-Azar in India has posed many problems. Apart from patients from endemic areas, cases are being reported from non-endemic areas also. In the present series, four out of 26 patients were from non-endemic areas. Other than diagnostic difficulties, resistance to stibogluconate and relapse are common problems which were seen in eight patients. The clinical profile of cases, their management, and how the problem of resistance was tackled are described.

Hyperglycemia in malnourished children with dehydrating gastroenteritis

Fifty patients with grade III and IV malnutrition with diarrhoeal dehydration were studied. Hyperglycemia was present in 5 cases at admission. Serum sodium levels were normal in all of them except one case who had hyponatremia. Blood sugar levels were normal in all the cases after rehydration with ORS. Possible mechanisms in pathogenesis of hyperglycemia are discussed.

Neuromuscular manifestations of diarrhea related hypokalemia

Twenty-three children from 8-60 months (mean age 21.13 months) admitted with neuromuscular manifestations of diarrhea related hypokalemia were studied. Forty four per cent cases were suffering from diarrhea at the time of admission but in majority of cases (56%), the diarrheal episode had already terminated. Mild hypokalemia was seen in 17.4%, moderate in 43.5% and severe in 39.1%. Neck flop was the commonest (100%) neuromuscular manifestations followed by diminished bowel sounds (82.6%), truncal weakness (52.2%), weakness of limbs (52.2%), lethargy (43. 5%), abdominal distension (43.5%), respiratory involvement (4.3%) and phantom hernia (4.3%). Two cases (8.7%) had flaccid paralysis of both the lower limbs. Severe hypokalemia was more frequently observed in children below 24 months of age and those who had received i.v. fluids or salt sugar solution before reporting in the hospital. A significant correlation was noticed between severity of hypokalemia and frequency of stools (p < 0.05), degree of dehydration (p < 0.01), severity of nutrition (p < 0.01) and extent of neuromuscular involvement (p < 0.01). Our results highlights the importance of diarrhea related hypokalemia particularly in young malnourished children who are rehydrated with solutions inadequate in potassium. Early diagnosis and appropriate treatment can promptly reverse these manifestations within 48-72 hours.

Persistent diarrhea: management in a diarrhea treatment unit

Five hundred ninety two children (6.0%) were diagnosed as persistent diarrhea (PD) out of a total attendance of 9795 cases in the Diarrhea Training and Treatment Unit (DTU) over a period of 1 year. Most of the cases were initially managed as outpatients on dietary advice and treatment of associated infections. Eighty eight per cent of the cases followed as outpatients from the DTU responded to treatment and only 11.5% of them had to be hospitalized. A total of 49/592 cases (8.3%) required to be hospitalized on account of treatment failure from outpatients and other indications. Clinical spectrum of hospitalized children included severe malnutrition (40.8%), pneumonia (40.8%), urinary tract infection (32.7%), lactose intolerance (32.7%), anemia (28.6%), septicemia (16.3%), dysentery (8.2%) and neck flop due to hypokalemia (4.1%). Dietary management included modifications in the diet already offered to hospitalized patients. Thirty eight children were fed on one of these diets. Of these 13/35 children (37.1%) were successfully managed with lactose reduced diet., 18/22 cases (81.8%) with lactose free diet and only in 2 cases carbohydrate free diet was given. In 3 cases, normal feeding was continued. Eleven cases were too sick to be offered any oral feeding. Eleven of forty nine cases (22.4%) expired. Mortality was highest in infants <6 months (31.6%). The causes of death included severe malnutrition (14.3%), septicemia (14.3%) and pneumonia (12.2%). Screening and treating cases of PD for associated infections like septicemia, pneumonia and urinary tract infection seems to be a key factor which determines morbidity and mortality in these cases. Feeding on a hospital food modified as lactose reduced/free diet can benefit majority of cases with PD and a very small proportion of cases may require carbohydrate free diet.

Activation of protein kinase C family members by the novel polyphosphoinositides PtdIns-3,4-P2 and PtdIns-3,4,5-P3

The effect of phosphoinositides on the activity of protein kinase C (PKC) isotypes was investigated. PKC alpha, beta I, beta II, gamma, delta, epsilon, eta, and zeta were expressed in baculovirus-infected insect cells and purified by column chromatography. The calcium-activated PKC isotypes alpha, beta I, beta II, and gamma were not significantly activated by any of the phosphoinositides investigated (phosphatidylinositol-4-phosphate (PtdIns-4-P), PtdIns-3-P, PtdIns-4,5-P2, PtdIns-3,4-P2, and PtdIns-3,4,5-P3) when added in the presence of concentrations of phosphatidylserine that give maximal stimulation. The calcium-insensitive PKC isotypes delta, epsilon, and theta also showed little response to PtdIns-3-P, PtdIns-4-P, or PtdIns-4,5-P2 when these lipids were added in the presence of phosphatidylserine. In contrast, PtdIns-3,4-P2 and PtdIns-3,4,5-P3 caused a 5-15-fold stimulation of these enzymes compared with phosphatidylserine alone. 50% maximal stimulation of PKC epsilon by PtdIns-3,4,5-P3 occurred when this lipid was present at about 1% of the carrier PtdIns-4,5-P2 (about 100 nM). These lipids had little effect on baculovirus-expressed PKC zeta, which was constitutively active. A short chain version of PtdIns-3,4,5-P3, dioctanoyl-PtdIns-3,4,5-P3, activated PKC delta, epsilon, and eta in the absence of other lipids, whereas a short chain version of PtdIns-4,5-P2, dihexanoyl-PtdIns-4,5-P2, did not. Since PtdIns-3,4-P2 and PtdIns-3,4,5-P3 are nominally absent in unstimulated cells and appear within seconds to minutes of stimulation by various cell activators, these lipids could act as second messengers to activate PKC delta, epsilon, or eta in vivo.

A study of childhood tetanus in post-neonatal age group in Delhi

A study was conducted in tetanus in the postneonatal pediatric age group between January, 1989 and June, 1991. Clinical profile of 55 patients was studied and outcome during this period was compared with previous years (1986-88). Although, an overall decline in total admissions was noted, only a modest decline in mortality was observed. All the patients but one were either unimmunized or incompletely immunized. More than 40% patients were from Delhi. Otorrhea was common (49.1%) in these patients. Primary immunization with booster dose in the community is stressed. Children with aural discharge should be taken as a high-risk group for tetanus and be evaluated for immunization at first visit.

Rotavirus as an aetiological organism in acute watery diarrhoea in Delhi children: reappraisal of clinical and epidemiological characteristics

Four-hundred children below 3 years of age with acute watery diarrhoea were studied over a 12-month period for detection of rotavirus (RV) antigen in the stool samples. Detection of RV antigen in the cases has been compared with 175 age-matched non-diarrhoea controls. Overall positivity for detection of RV antigen was 6 per cent which is much lower than earlier studies. Even during the peak season the RV antigen detection was positive only in 13 per cent cases. However, RV antigen detection was significantly higher in cases than in the controls (P < 0.05). No significant correlation was noticed between the detection of RV antigen in the stool and environmental temperature, rainfall, and relative humidity except for higher percentage of RV antigen detection between February and April. Clinical profile of cases with RV antigen-positive stools has been compared with RV antigen-negative controls. Preceding history of vomiting and respiratory symptoms were noticed in higher percentage of RV antigen-positive cases, but no reliable 'clinical predictor' could be identified to differentiate RV diarrhoea from non-RV diarrhoea. Presence or absence of fecal polymorphonuclear leucocytes do not seem to rule out or suggest RV diarrhoea.

Vitamin A deficiency in children with acute diarrhoea

Ninety-five children between 9 months and 3 years (mean age 14.4 months) with acute diarrhoea were enrolled by simple random sampling and studied for the presence of xerophthalmia and subclinical vitamin-A deficiency (detected by ocular impression cytology). The objective of the study was to estimate the prevalence of vitamin-A deficiency in these children and to evaluate its role as a risk factor for acute diarrhoea. The results were compared with 96 sex-and age-matched (mean age 15.79 months) controls belonging to similar nutritional grades and socioeconomic status who did not have diarrhoea and attended the hospital for treatment of minor ailments or for immunizations. Clinically evident xerophthalmia was observed in 12.6% of cases with acute diarrhoea and in 10.4% of controls. Ocular impression cytology suggested vitamin-A deficiency in 48.4% of cases and 40.6% of controls. However, on comparing the study group with the controls, there was no significant difference in vitamin-A deficiency in the 2 groups on clinical examination (p > 0.05) or by ocular impression cytology (p > 0.05). The prevalence rate of vitamin-A deficiency increased with the severity of malnutrition in cases (p < 0.05) as well as in controls (p < 0.05), but subclinical vitamin-A deficiency was detected even in well-nourished cases (35%) and controls (22.7%). Our results suggest a high prevalence of vitamin-A deficiency in young children from our study population with or without diarrhoea and even in well-nourished children. The association of vitamin-A deficiency was not significantly different in cases of acute diarrhoea than in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenal string test in typhoid fever

Twenty five children between 4-12 years of age hospitalized with a clinical diagnosis of enteric fever were studied for evaluating the practicality and sensitivity of duodenal string-capsule culture (DSCC) and compared with conventional cultures from blood (BC), urine (UC) and stool (SC). Duodenal string capsule (DSCC) was successfully inserted in 18 patients (72%). Insertion of DSCC failed in 7 patients (28%) and all of them were below 6 years of age. Salmonella typhi was isolated from DSCC and/or BC in 13 cases (72.2%). DSCC was positive in 11 out of 13 confirmed cases of typhoid fever (84.6%). BC was positive in 8 cases (61.5%). DSCC was successful in isolating the organism in about 30% more cases than BC. Duodenal string test was a simple, non-invasive and a reliable test which when used in combination with BC could identify almost all cases of enteric fever irrespective of duration of fever and prior use of antibiotics.

Nutritional disorders in adolescent girls

Four hundred and fifty four adolescent girls (11-18 years) were screened for nutritional disorders by anthropometry (weight, height and triceps skinfold measurements), clinical examination and hemoglobin estimation. Of these, 56% belonged to high socio-economic groups (Group A) and the rest (44%) to lower middle class (Group B). A large number of girls from Group B were undernourished (35.5% had weight/height2 less than the fifth percentile of reference standard) stressing the need for nutritional screening, nutrition and health education. Obesity was prevalent in 3.1% of Group A adolescents. Goitre grade I or more was observed in a high proportion of Group B girls, stressing the need for continued consumption of iodized salt in Delhi. Anemia appears to be a major health problem in adolescent girls in both groups (47, 56% in Groups A and B, respectively) underlying the ned for iron supplementation along with health education.

Errors in medication in a pediatric ward

Iatrogenic errors in medication were studied in a busy pediatric ward. The study was based on voluntary reporting of errors noticed by the doctors and nurses in the ward. The error rate was 6.4%. Prescription errors accounted for 37.7% of the errors and 2 of these were potentially fatal. Dispensing errors and missed dosages were other frequent errors. Overcrowding in pediatric wards is an obstacle to optimum patient care. Adequate number of nurses and support of pharmacists is essential for safe and optimum drug therapy.

Oral rehydration therapy in severely malnourished children with diarrheal dehydration

Fifty patients of grade III & IV malnutrition with diarrhoeal dehydration were rehydrated using the WHO recommended ORS. Serum sodium and potassium levels were estimated at admission and 24 hours later. Forty seven patients were successfully rehydrated orally. In 7 patients the level of dehydration at initial assessment was overestimated. Periorbital edema developed in 25.5% of the patients rehydrated. No patient had cardiac failure or convulsions during therapy. Though persistent hyponatremia and hypokalemia were found in 10.6% and 19.15% cases respectively after rehydration, the incidence decreased as compared to the pre-hydration levels and was comparable to that found in malnourished children without diarrhea who served as controls in the present study. Oral rehydration was discontinued in three patients due to development of excessive vomiting in one case and paralytic ileus in two. Thus WHO ORS can be used safely in children with severe malnutrition but constant monitoring is required.

Multidrug resistant typhoid fever: therapeutic considerations

Forty six blood culture positive cases were studied during the current outbreak of multidrug resistant typhoid fever (MRTF). The present outbreak was caused by E1 phage type and organisms were resistant to all commonly used drugs for the treatment of typhoid fever, viz., chloramphenicol (78%), co-trimoxazole (76%) and ampicillin (68%). Treatment failures with chloramphenicol (45.5%) corroborated well with in vitro resistance. No treatment failure was seen with chloramphenicol and ceftriaxone, when these drugs were used in cases infected with sensitive strains. Among the alternative drugs used in cases with in vitro sensitivity, successful clinical response was seen with ceftriaxone (4/4) and cefotaxime (8/9) as compared to cephalexin (3/5) or a combination of cephalexin and furazolidone (9/12).

Diarrhea training and treatment unit: experience from a teaching hospital

Case management of children with diarrhea has been evaluated after the establishment of a Diarrhea Training and Treatment Unit (DTU) in Kalawati Saran Children's Hospital, New Delhi. Our one year experience has shown a decrease in hospital admissions on account of diarrhea by 13%. With the help of proper treatment protocol, 69.5% of total cases have been managed with home available fluids/ORS after educating the mothers on home management of diarrhea. Majority of admitted cases (80.7%) were managed in the ORT area and rehydrated under proper monitoring and supervision between 3-8 hours (mean duration of stay 4.28 +/- 1.8 hours). Out of 1951 cases with dehydration, 1585 patients (81.2%) were rehydrated with ORS and only 366 cases (18.8%) received intravenous fluids. In more than 85% of cases with associated vomiting, successful oral rehydration was achieved with ORS. Use of ORS and early feeding even in those patients who initially received intravenous fluids for rehydration significantly reduced the average duration of stay in the diarrhea ward (P = less than 0.001). During the first year of its inception the average cost of rehydrating one patient of diarrhea in the DTU came down to Rs. 18.54 from Rs. 31.69 in the preceding year. Rationalising drug therapy in the case management helped to significantly reduce the consumption of antibiotics (P = less than 0.001) and antiemetics (P = less than 0.001), which has helped to reduce the expenditure on drugs on an average from Rs. 17.60 to Rs. 4.92 per patient.

A clinical profile of multidrug resistant typhoid fever

Fifty blood culture positive patients of typhoid fever were studied during the current outbreak of the disease for their clinical profile. In 39 (78%) cases the isolates of S. typhi were resistant to conventional drugs. Children below 2 years of age constituted 20% of the total cases and belonged exclusively to the group with multidrug resistant typhoid fever (MRTF). The clinical presentation seemed to mimic malaria, bronchopneumonia, meningitis, etc. Typhoid hepatitis was diagnosed in 2 cases with MRTF. Life threatening complications were seen in 28.2% patients and were observed exclusively in MRTF group.

Knowledge and perceptions of residents regarding case management of acute diarrhea

The knowledge and perceptions about case management of acute diarrhea were studied amongst 330 resident doctors working in Pediatric Departments of various Medical Colleges in the country. Our observations highlight the inadequacies in the medical curriculum and deficient clinical training in the management of acute diarrhea in the teaching institutions. Knowledge of signs of dehydration was correctly perceived by only 79.8% interns, 80.9% house physicians and 81.1% postgraduate students. It was appalling to observe that despite spending 1-3 years in pediatric wards, the knowledge and perceptions of postgraduate students had not significantly improved. On the contrary, the responses of postgraduate students were poorer as compared to interns in their perceptions of use of ORT in moderate dehydration (p less than 0.005) and in presence of vomiting (p less than 0.05). Adequate thrust on diarrhea and its management during undergraduate as well as during postgraduate teaching and proper training in diarrhea case management with "hands on training" needs to be viewed as a priority in the teaching institutions.

Triceps skinfold thickness in adolescents

The triceps skinfold thickness (TSF) was measured in 1000 healthy adolescents aged 11 to 18 yr. Measurements were made with the Standard Harpenden skinfold caliper. Females at all ages studied had thicker skinfolds than their male counterparts. Significant differences in skinfold fat were observed between the high and low socio-economic groups, in both sexes. TSF thickness among girls showed a steady gain throughout adolescence. In boys however, there was a dip in TSF followed by a slow rise, the final thickness being somewhat lower than the prepubertal value. TSF was found to have no correlation with height but good positive correlation with weight and wt/ht2 (body mass index). Hence it may be regarded as a reliable indicator of obesity in this age group, where variable pubertal growth makes nutritional assessment difficult.

Plain radiograph skull: is it really needed in epilepsy?

One hundred and three children with seizure disorder were studied. Plain radiograph skull was normal in all the cases. CT scan skull done in 34 patients, showed abnormalities in 24 cases. More than 80% children in partial seizures group had treatable lesions on CT scans, mainly CNS tuberculoma. The need for omitting plain radiograph skull as a routine investigation for epilepsy cases is emphasized.

Urinary schistosomiasis in schoolchildren

Two hundred schoolboys aged from 5–18 years with urinary schistosomiasis were studied. Terminal haematuria was observed to be the commonest presentation, though haematuria may be microscopic initially. Haematuria was painless in only a small percentage of cases, as most of them had associated urinary symptoms. Pain and burning sensation in the epigastrium was an outstanding feature of recent onset of schistosomiasis. Most cases had moderate proteinuria which was directly related to intensity of haematuria and egg count in urine. Ignorance about the transmission of the disease, false cultural beliefs and poor drug compliance seem to be important factors in the high prevalence in children. An extensive health education campaign, particularly in educational institutions, will help to control the disease in endemic areas.

Hepatic dysfunction in childhood malaria

Hepatic function of 80 children aged under 3 years with Plasmodium vivax malaria were studied during the acute attack and 6 weeks after antimalarial treatment. Raised levels of serum aspartate transaminase (serum AST; SGOT), serum alanine transaminase (serum ALT; SGPT), and alkaline phosphatase were observed in 68%, 39% and 46% of cases respectively. AST levels were higher than ALT ones and the mean level of both enzymes was much higher in patients with hepatomegaly. The hepatic dysfunction which these observations reflect is transient, as these enzymes were found to be at their normal levels 6 weeks after treatment. A transient derangement of liver function is thus a common feature of childhood malaria, and hepatic dysfunction takes place to a significant degree even in P. vivax malaria.

Edward’s syndrome with a novel karyotype

Edward’s syndrome was first described as a clinical entity in 1960 as a disorder of trisomy 18 (47 XX/XY; + 18) in babies with particular pattern of malformations. The Karyotype found in our case was (47 XX + 18 add (22) (p13) which has not been published so far in the literature. The less common findings noted in the baby were rocker bottom feet, syndactyly of 2nd and 3rd toes, microcephaly and corneal opacities. Though we didn’t find any significant association between phenotypic ranges with genotypic variation in literature, but further research is needed for it. We are reporting this case as the genotype is found to be novel. Keywords: Edward’s syndrome, karyotype, neonate. DOI: http://dx.doi.org/10.3329/bjms.v10i3.8368 BJMS 2011; 10(3): 211-212