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Doshi K, Raina R, Ng KH, Koch V, Bhatt GC, Nada A, Foresi B, Kamalakkannan SS, McCulloch M, Sethi S, de Ferris MDG. Health-related quality of life for pediatric patients with end-stage kidney disease: A systematic review and meta-analysis of the Pediatric Quality of Life Inventory (PedsQL). Hemodial Int 2024; 28:198-215. [PMID: 38468403 DOI: 10.1111/hdi.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/17/2023] [Accepted: 01/30/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Health-related quality of life (HRQoL) studies demonstrate the impact of end-stage renal disease (ESRD) on the physical and psychosocial development of children. While several instruments are used to measure HRQoL, few have standardized domains specific to pediatric ESRD. This review examines current evidence on self and proxy-reported HRQoL among pediatric patients with ESRD, based on the Pediatric Quality of Life Inventory (PedsQL) questionnaires. METHODS Following PRISMA guidelines, we conducted a systematic review and meta-analysis on HRQoL using the PedsQL 4.0 Generic Core Scale (GCS) and the PedsQL 3.0 ESRD Module among 5- to 18-year-old patients. We queried PubMed, Embase, Web of Science, CINAHL, and Cochrane databases. Retrospective, case-controlled, and cross-sectional studies using PedsQL were included. FINDINGS Of 435 identified studies, 14 met inclusion criteria administered in several countries. Meta-analysis demonstrated a significantly higher total HRQoL for healthy patients over those with ESRD (SMD:1.44 [95% CI: 0.78-2.09]) across all dimensional scores. In addition, kidney transplant patients reported a significantly higher HRQoL than those on dialysis (PedsQL GCS, SMD: 0.33 [95% CI: 0.14-0.53]) and (PedsQL ESRD, SMD: 0.65 [95% CI: 0.39-0.90]) concordant with parent-proxy reports. DISCUSSION Patients with ESRD reported lower HRQoL in physical and psychosocial domains compared with healthy controls, while transplant and peritoneal dialysis patients reported better HRQoL than those on hemodialysis. This analysis demonstrates the need to identify dimensions of impaired functioning and produce congruent clinical interventions. Further research on the impact of individual comorbidities in HRQoL is necessary for developing comprehensive, integrated, and holistic treatment programs.
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Affiliation(s)
- Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Kar Hui Ng
- Department of Paediatrics, National University of Singapore, Singapore
| | - Vera Koch
- Department of Pediatrics, University of Sao Paulo Medical School, Pediatric Nephrology Unit Instituto da Criança, Hospital das Clinicas University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Girish C Bhatt
- Division of Pediatric Nephrology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Brian Foresi
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | | | - Mignon McCulloch
- Department of Paediatrics and Child Health, University of Cape Town, Rondebosch, South Africa
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, India
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Subhash S, Satariano M, Doshi K, Bhatt GC, Raina R. Hypertension monitoring on cardiac health outcomes. Transl Pediatr 2024; 13:518-524. [PMID: 38590375 PMCID: PMC10998995 DOI: 10.21037/tp-23-527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/03/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Sanat Subhash
- Department of Biological Sciences, Youngstown State University, Youngstown, OH, USA
| | - Matthew Satariano
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Girish C. Bhatt
- Division of Pediatric Nephrology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
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Raina R, Shah R, Hong G, Bhatt GC, Abboud B, Jain R, Chanchlani R, Sethi SK. Cardiovascular implications of hypertensive autosomal dominant polycystic kidney disease: a systematic review and meta-analysis. Pediatr Nephrol 2023; 38:2957-2972. [PMID: 36811694 DOI: 10.1007/s00467-023-05893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is among the most common inherited kidney diseases. Hypertension is a frequent cardiovascular manifestation, especially in adults, but elevated blood pressure is also found in children and adolescents. Acknowledgment of pediatric hypertension early is critical, as it can result in serious complications long-term if left undiagnosed. OBJECTIVE We aim to identify the influence of hypertension on cardiovascular outcomes, mainly left ventricular hypertrophy, carotid intima media thickness, and pulse wave velocity. METHODS We performed an extensive search on Medline, Embase, CINAHL, and Web of Science databases through March 2021. Original studies with a mix of retrospective, prospective, case-control studies, cross sectional studies, and observational studies were included in the review. There was no restriction on age group. RESULTS The preliminary search yielded 545 articles with 15 articles included after inclusion and exclusion criteria. In this meta-analysis, LVMI (SMD: 3.47 (95% CI: 0.53-6.41)) and PWV (SMD: 1.72 (95% CI: 0.08-3.36)) were found to be significantly higher in adults with ADPKD compared to non-ADPKD; however, CIMT was not found to be significantly different. Also, LVMI was observed to be significantly higher among hypertensive adults with ADPKD (n = 56) as compared to adults without ADPKD (SMD: 1.43 (95% CI: 1.08-1.79)). Fewer pediatric studies were available with heterogeneity among patient populations and results. CONCLUSIONS Adult patients with ADPKD were found to have worse indicators of cardiovascular outcomes, including LVMI and PWV, as compared to non-ADPKD. This study demonstrates the importance of identifying and managing hypertension, especially early, in this population. Further research, particularly in younger patients, is necessary to further elucidate the relationship between hypertension in patients with ADPKD and cardiovascular disease. REGISTRATION NUMBER PROSPERO REGISTRATION: 343,013.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Raghav Shah
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Gordon Hong
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Girish C Bhatt
- Division of Pediatric Nephrology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Brian Abboud
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Rohit Jain
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Siddharth Kumar Sethi
- Paediatric Nephrology & Paediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
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Pathak A, Rai J, Rai NK, Singh R, Bhatt GC. Effectiveness of rehabilitation strategies in primary fibromyalgia syndrome: A systematic review and meta-analysis. Br J Pain 2023; 17:375-399. [PMID: 37538942 PMCID: PMC10395393 DOI: 10.1177/20494637231168021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Objectives The aim of this review was to (1) summarize evidence on the effectiveness of rehabilitation strategies in fibromyalgia syndrome (FMS) and (2) determine the most effective rehabilitation strategy for reducing pain and depression in people with FMS. Data Sources PubMed, Ovid (Sp), and Cochrane search engines were used for identifying relevant studies done up to 1st of July 2022. Study Selection Randomized control trials (RCTs) that have a passive control group and an active control group were included in this review for primary and secondary aim, respectively. The primary outcome measures were pain and depression. Secondary outcome was one from the sleep or fatigue or healthy related quality of life (HRQOL). Data Extraction Two researchers independently selected the studies and extracted the key information. Data Synthesis A total of 25 RCTs were included. Studies with passive control group showed moderate to large positive effects on pain (standard mean difference -0.65, 95% confidence interval -0.93 to -0.38; I2 = 72%) and HRQOL (MD -5.40, 95% CI -10.17 to -0.62; I2 = 74%) but were not statistically significant for sleep, fatigue, and depression. Furthermore, on subgroup analysis studies with a short term protocol showed significant effects on pain only, whereas studies with long term protocols showed positive effects on pain and HRQOL only, but no statistical significance at the time of post-trial follow-up. Studies with active control groups gave non-significant results except where there was mixed exercises, which showed a positive effect (mean difference -4.78, 95% CI -7.98 to -1.57; I2 = 0%) for HRQOL. Conclusion All rehabilitation strategies were effective for pain and HRQOL, and had a marginal effect on depression, sleep, and fatigue but efficacy was not maintained at the time of post-trial follow-up. However, in this review, we could not differentiate any rehabilitation strategies for the best among those used in the included studies.
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Affiliation(s)
- Akash Pathak
- Department of Physiology, All India Institute of Medical Sciences, Bhopal, India
| | - Jyotsana Rai
- Department of Physiology, All India Institute of Medical Sciences, Bhopal, India
| | - Nirendra K. Rai
- Department of Neurology, All India Institute of Medical Sciences, Bhopal, India
| | - Ruchi Singh
- Department of Physiology, All India Institute of Medical Sciences, Bhopal, India
| | - Girish C. Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
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Raina R, Shah R, Marks SD, Johnson JN, Nied M, Bhatt GC, Bonham CA, Datla N, Sethi SK, Bartosh SM. The effects of COVID-19 on pediatric and adult solid organ transplant recipients and the emergence of telehealth. Pediatr Transplant 2023; 27:e14490. [PMID: 36879358 DOI: 10.1111/petr.14490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND The SARS-CoV-2 pandemic and corresponding acute respiratory syndrome have affected all populations and led to millions of deaths worldwide. The pandemic disproportionately affected immunocompromised and immunosuppressed adult patients who had received solid organ transplants (SOTs). With the onset of the pandemic, transplant societies across the world recommended reducing SOT activities to avoid exposing immunosuppressed recipients. Due to the risk of COVID-19-related outcomes, SOT providers adapted the way they deliver care to their patients, leading to a reliance on telehealth. Telehealth has helped organ transplant programs continue treatment regimens while protecting patients and physicians from COVID-19 transmission. This review highlights the adverse effects of COVID-19 on transplant activities and summarizes the increased role of telehealth in the management of solid organ transplant recipients (SOTRs) in both pediatric and adult populations. METHODS A comprehensive systematic review and meta-analysis were conducted to accentuate the outcomes of COVID-19 and analyze the efficacy of telehealth on transplant activities. This in-depth examination summarizes extensive data on the clinical detriments of COVID-19 in transplant recipients, advantages, disadvantages, patient/physician perspectives, and effectiveness in transplant treatment plans via telehealth. RESULTS COVID-19 has caused an increase in mortality, morbidity, hospitalization, and ICU admission in SOTRs. Telehealth efficacy and benefits to both patients and physicians have increasingly been reported. CONCLUSIONS Developing effective systems of telehealth delivery has become a top priority for healthcare providers during the COVID-19 pandemic. Further research is necessary to validate the effectiveness of telehealth in other settings.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Raghav Shah
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK.,Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Nied
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Girish C Bhatt
- Division of Pediatric Nephrology, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Clark A Bonham
- Division of Abdominal Transplant Surgery, Stanford University School of Medicine, California, USA
| | - Nithin Datla
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Sidharth Kumar Sethi
- Paediatric Nephrology & Paediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Sharon M Bartosh
- Division of Pediatric Nephrology, University of Wisconsin, Madison, Wisconsin, USA
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Atlani M, Bhatt GC, Tarachandani D, Charan V. Hypertriglyceridemia with pancreatitis at disease onset in systemic lupus erythematosus. BMJ Case Rep 2023; 16:16/1/e250166. [PMID: 36599492 PMCID: PMC9815037 DOI: 10.1136/bcr-2022-250166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterised by the presence of several autoantibodies, immune complex formation and multiple organ system involvement. SLE has a wide range of manifestations involving nearly all organ systems. Hypertriglyceridemia (HTG) in SLE is a well-established and a common abnormality, which is generally mild and not included in the diagnostic criteria of SLE. HTG as the initial manifestation of SLE in adult patients in association with acute pancreatitis at levels below 1000 mg/dL has not been previously reported. Here, we report a case of rare presentation of moderate HTG (TG-869 mg/dL) with pancreatitis at disease onset in an adult women which later proved to be due to SLE and progressed to levels of severe HTG during the course of illness. The patient was successfully treated with plasma exchanges and cyclophosphamide.
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Affiliation(s)
| | - Girish C Bhatt
- Division of Pediatric Nephrology, Department of Pediatrics, AIIMS Bhopal, Bhopal, Madhya Pradesh, India
| | - Divya Tarachandani
- General Medicine, All India Institute of Medical Science-Bhopal, Bhopal, Madhya Pradesh, India
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7
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Kundavaram R, Sharma T, Joshi D, Kumar A, Malik S, Bhatt GC. Bland Urine Sediment in a Child with Acute Kidney Injury. J Lab Physicians 2022; 15:152-155. [PMID: 37064964 PMCID: PMC10104720 DOI: 10.1055/s-0042-1750068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
AbstractTubulointerstitial nephritis (TIN) or acute interstitial nephritis (AIN) is a renal lesion characterized by inflammatory infiltrate limited to the renal interstitium and tubules. Three-fourths of the cases are drug induced, other causes being systemic and autoimmune diseases, and infections. Various drugs have been implicated, the most common being antibiotics such as β-lactams. Cephalosporins causing AIN have been reported uncommonly, particularly in children. Although renal biopsy confirms the diagnosis, urinalysis provides pertinent diagnostic clues against the backdrop of the clinico-laboratory profile. The presence of white blood cells, white cell casts, and red blood cells in urine sediment have been described in literature. However, a relatively normal urinalysis may be present in some cases and may pose a diagnostic challenge. We present a case of ceftriaxone-induced AIN in a child with bland urine sediment at initial presentation. To the best of our knowledge, this is the first report of ceftriaxone-induced AIN in the pediatric age group.
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Affiliation(s)
- Rajkumar Kundavaram
- Department of Pediatrics, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Tanya Sharma
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Deepti Joshi
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Amber Kumar
- Department of Pediatrics, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Shikha Malik
- Department of Pediatrics, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Girish C. Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
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Kotnis A, Bhatt GC, Joshi D, Shukla AK, Gupta P, Shah D, Choudhary B, Patil R, Dubey SK, Shukla M, Joshi A, Pakhare AP. Assessment of zinc inadequacy among tribal adolescent population of central India - A cross-sectional study. Indian J Med Res 2022; 156:339-347. [PMID: 36629194 PMCID: PMC10057370 DOI: 10.4103/ijmr.ijmr_3130_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background & objectives Zinc is a crucial micronutrient in adolescence, required for promoting growth and sexual maturation. Adolescents of some tribes may be at high risk of zinc deficiency due to dietary inadequacy and poor bioavailability of zinc from plant-based diets. This study aimed to evaluate the risk of zinc deficiency by estimating prevalence of inadequate zinc intake, prevalence of low serum zinc and stunting among tribal adolescents. Methods A cross-sectional community-based survey was conducted among adolescents (10-19 yr) in three purposively selected districts where Bhil, Korku and Gond tribes were in majority. Structured data collection instrument comprising information about sociodemographic characteristics and dietary recall data was used. Anthropometric assessment was conducted by standardized weighing scales and anthropometry tapes, and blood sample was collected from antecubital vein into trace element-free vacutainers. Serum zinc was estimated using an atomic absorption spectrophotometer. Results A total of 2310 households were approached for participation in the study, of which 2224 households having 5151 adolescents participated. Out of these enlisted adolescents, 4673 responded to dietary recall (90.7% response rate). Anthropometry of 2437 participants was carried out, and serum zinc was analyzed in 844 adolescents. The overall prevalence of dietary zinc inadequacy was 42.6 per cent [95% confidence interval (CI) 41.2 to 44.1] with reference to the estimated average requirement suggested by International Zinc Nutrition Consultative Group (IZiNCG) and 64.8 per cent (95% CI 63.4 to 66.2) with Indian Council of Medical Research-recommended requirements. Stunting was observed in 29 per cent (95% CI 27.2 to 30.8) participants. According to IZiNCG cut-offs, low serum zinc was detected in 57.5 per cent (95% CI 54.1 to 60.8) of adolescents, whereas it was 34.4 per cent (95% CI: 31.2-37.5) according to the national level cut-off. Interpretation & conclusions Risk of dietary zinc inadequacy and low serum zinc concentration amongst adolescents of the Gond, Bhil and Korku tribes is a public health concern.
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Affiliation(s)
- Ashwin Kotnis
- Department of Biochemistry, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Deepti Joshi
- Department of Pathology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Arvind K Shukla
- Department of Micronutrients, Indian Institute of Soil Sciences, Bhopal, Madhya Pradesh, India
| | - Palak Gupta
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Dishant Shah
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bharat Choudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh; Department of Trauma & Emergency Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rajesh Patil
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shiv Kumar Dubey
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Mukesh Shukla
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh; Department of Community Medicine, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
| | - Ankur Joshi
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Abhijit P Pakhare
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Pilania RK, Dokania S, Kumar A, Ahmad R, Malik S, Bhatt GC. Acute Renal Failure Requiring Renal Replacement Therapy: Unusual Presentation of Multisystem Inflammatory Syndrome in Children. J Paediatr Child Health 2021; 57:1724-1725. [PMID: 34467603 DOI: 10.1111/jpc.15715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Rakesh K Pilania
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Swati Dokania
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Amber Kumar
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Reyaz Ahmad
- Deparment of Pediatric Surgery, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Shikha Malik
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
| | - Girish C Bhatt
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, All India Institute of Medical Sciences (AIIMS), Bhopal, India
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Dubey SRK, Shrivastava N, Sharma T, Bhatt GC, Dhingra B, Pakhare AP, Goel SK, Joshi D. Abnormal Ambulatory Blood Pressure and Early Renal Dysfunction in Sickle Cell Disease. Indian J Pediatr 2021; 88:562-567. [PMID: 33175364 DOI: 10.1007/s12098-020-03558-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES There is sparsity of studies evaluating blood pressure in children with sickle cell disease (SCD), which have shown inconsistent results. Few of the studies have documented lower office blood pressure (BP) in SCD patients, whereas, others have shown presence of masked hypertension and abnormal ambulatory blood BP monitoring (ABPM). Thus, the present study was conducted to examine 24 h ABPM parameters and renal dysfunction in children with SCD and compare them with healthy controls. METHODS A cross-sectional study was conducted on 56 children (30 children having SCD and 26 controls). ABPM and evaluation of renal functions including serum creatinine, serum urea, urinary creatinine, urinary protein and specific gravity was performed. RESULTS Spot urinary protein to creatinine ratio was found to be higher in patients with SCD (63.3%) as compared to controls (p < 0.001). Proteinuria was observed in 1/4th of the SCD patients less than ten years of age. Masked hypertension was present in 2 (6.6%) patients, ambulatory hypertension in 4 (13.3%), ambulatory pre-hypertension in 1 (3.3%) and abnormal dipping in 60%. A statistically significant correlation of BMI for age Z-score and standard deviation score (SDS/Z) of 24 h systolic BP (r = 0.56, p = 0.002); estimated glomerular filtration rate (eGFR) with 24 h diastolic BP SDS (r = -0.52; p = 0.038) and age with e GFR (r = 0.54; p = 0.025) was found in the present study. CONCLUSIONS The present study corroborates that ABPM abnormalities (ambulatory hypertension, non-dipping pattern, ambulatory prehypertension) and early onset proteinuria are significant findings in patients with SCD. This underscores the importance of regular screening for proteinuria and ABPM in routine care, for early detection and prevention of progressive renal damage in SCD.
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Affiliation(s)
- Shiv Ram Krishna Dubey
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.,Department of Pediatrics, Government Medical College, Vidisha, Madhya Pradesh, India
| | - Neha Shrivastava
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.,Department of Pediatrics, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Tanya Sharma
- Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.
| | - Bhavna Dhingra
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India
| | - Abhijit P Pakhare
- Department of Community & Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - S K Goel
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Deepti Joshi
- Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Bhatt GC, Das RR, Satapathy A. Early versus Late Initiation of Renal Replacement Therapy: Have We Reached the Consensus? An Updated Meta-Analysis. Nephron Clin Pract 2021; 145:371-385. [PMID: 33915551 DOI: 10.1159/000515129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/05/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The objective of this study is to compare early versus late/standard initiation of renal replacement therapy (RRT) in patients with acute kidney injury (AKI). DATA SOURCES MEDLINE/PubMed, Embase, Google Scholar, Cochrane Central Register of Controlled Trials, and the Cochrane renal group till August 15, 2020. STUDY SELECTION Randomized controlled trials (RCTs) comparing early versus late initiation of RRT in patients with AKI were included. The primary outcome measures were all-cause mortality and dialysis dependence on day 90. Secondary outcome measures were length of stay, recovery of renal functions, and adverse events. DATA EXTRACTION Two authors independently performed study selection and data extraction using data extraction forms. DATA SYNTHESIS A total of 14 RCTs with 5,234 participants were included. Three trials had low risk of bias in all the domains. There was no significant difference in the overall mortality (risk ratio (RR): 0.99; 95% confidence interval (CI): 0.89, 1.10; moderate certainty of evidence), day 30 mortality (RR: 1.0; 95% CI: 0.91, 1.09; high certainty of evidence), day 90 mortality (RR: 1.00; 95% CI: 0.88, 1.13; high certainty of evidence), and ICU mortality (RR: 1.00; 95% CI: 0.90, 1.10; moderate certainty of evidence) between the early versus late RRT. Dialysis dependence on day 90 was significantly higher in the patients assigned to early RRT (RR: 1.55; 95% CI: 1.15, 2.09; moderate certainty of evidence). The treatment-emergent adverse events (hypophosphatemia and hypotension) were significantly higher in the patients assigned to early RRT. CONCLUSION There is no added benefit of early initiation of RRT in patient with AKI; this may lead to treatment-emergent adverse events. Delaying the initiation of RRT with close monitoring and initiating RRT for emergent indications should be the acceptable criterion in critical care nephrology. Prospero Registration: CRD42016043092.
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Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, AIIMS, Bhopal, India
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Jain S, Bhan BD, Bhatt GC. Complementary feeding practices and their determinants among children 6-23 months of age in an outpatient hospital setting in Central India: A cross-sectional study. J Family Med Prim Care 2020; 9:1187-1190. [PMID: 32318490 PMCID: PMC7114014 DOI: 10.4103/jfmpc.jfmpc_958_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: To study and profile complementary feeding practices and their determinants among children 6–23 months of age in an outpatient hospital setting in Central India: A cross-sectional study. Method: Total 464 Children, 6-23 months of age, visiting Well baby clinic and Immunization center at AIIMS Bhopal during February 2015 to June 2016, where parents had given consent for participation in the study were included. Children with congenital malformations affecting feeding, cerebral palsy, known chronic systemic diseases, were excluded. Result: Breastfeeding was initiated within 1 hour in 59.5%. Complementary feeds were given in 84% of children 6-8 month of age. Minimal dietary diversity as determined by WHO was received by 57% of children while minimal meal frequency was present in 86%. Minimal acceptable diet was received by 58% of children. Breastfeeding was continued in 86% children at 1 year of age and 41% children at 2 years of age. Bottle feeding was present in 26% of children. Multivariate regression analysis was done to correlate minimum acceptable diet and various variables affecting the feeding habits. Higher maternal education (adjusted OR: 4.03; 95% CI: 2.35–6.89) and income group (adjusted OR: 2.03; 95% CI: 1.11–3.72) were found to be significant. Joint families had better feeding practices when compared to nuclear families (adjusted OR: 1.72; 95% CI: 1.12–2.64). Homemaker mothers were able to feed their children in more appropriate way (adjusted OR: 3.33; 95% CI: 1.17–6.62). Conclusion: Well-educated homemaker mother, higher income group, and joint families help in establishing better complementary feeding habits in children less than 2 years. An understanding of the prevalent practices will be helpful in identification of areas that need to be focused upon and reemphasized during counseling the caregivers of the young children to improve their nutritional status, which will also reduce the burden of disease at primary care.
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Affiliation(s)
- Shikha Jain
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Bhavna D Bhan
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Mishra NR, Panigrahi MK, Bhatt GC, Das RR. Corticosteroid as an Adjunct in the Treatment of Endobronchial Tuberculosis: A Systematic Review & Meta-analysis. Curr Pediatr Rev 2020; 16:53-60. [PMID: 31622209 DOI: 10.2174/1573396315666191016100615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/08/2019] [Accepted: 09/16/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Corticosteroid exerts anti-inflammatory action and can prevent tissue damage resulting from various causes. Studies have shown that corticosteroids may prevent the damaging effect of tuberculosis (TB) in various organs, but there is no published meta-analysis specifically looking for the effect of corticosteroid in endobronchial TB. OBJECTIVE To synthesize the evidence regarding the usefulness of corticosteroid in endo-bronchial TB. METHODS A comprehensive search was performed of the major electronic databases till 30th November 2018. Randomized trials comparing treatment with corticosteroid as an adjunct to antitubercular drugs (ATT) versus placebo/no treatment in endobronchial TB were included. Three authors independently applied eligibility criteria, assessed the studies for methodological quality, and extracted data. The review is registered at PROSPERO database [CRD42016047063]. RESULTS Out of 525 search results, 4 trials including 205 patients (151 children) were eligible for inclusion. Oral prednisolone was used in various dose schedules. Rifampicin containing ATT regimen was used in 3 trials. The bronchoscopy findings showed no significant improvement at 1 month (effect size could not be calculated due to 0 event in the intervention group, p = 0.05), 2 months (RR 1.26, 95% CI 0.89 to 1.8), and at completion of ATT (RR 0.63, 95% CI 0.1 to 4.14) in steroid-treated group compared to the control group. The need for repeat bronchoscopy was significantly decreased in the steroid group (RR 0.13, 95% CI 0.02 to 0.9). Among the adverse events, the infection rate was significantly lesser in the steroid group (RR 0.53, 95% CI 0.29 to 0.97); but other adverse events (mortality, hypertension, and abdominal distension) showed no significant difference between the two groups. The GRADE evidence generated was of very low quality. CONCLUSION The present meta-analysis showed that oral steroid does not help patients with endobronchial tuberculosis. However, the quality of evidence was very low. Future trials with robust design and a larger sample size would be required to provide any firm recommendation regarding the use of oral prednisolone in endobronchial tuberculosis.
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Affiliation(s)
| | | | | | - Rashmi R Das
- Department of Pediatrics, AIIMS, Bhubaneswar, India
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Bhatt GC, Pakhare AP, Gogia P, Jain S, Gupta N, Goel SK, Malik R. Predictive Model for Ambulatory Hypertension Based on Office Blood Pressure in Obese Children. Front Pediatr 2020; 8:232. [PMID: 32509711 PMCID: PMC7248329 DOI: 10.3389/fped.2020.00232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 04/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background: The epidemic of obesity, along with hypertension (HT) and cardiovascular disease, is a growing contributor to global disease burden. It is postulated that obese children are predisposed to hypertension and subsequent cardiovascular disease in adulthood. Early detection and management of hypertension in these children can significantly modify the course of the disease. However, there is a paucity of studies for the characterization of blood pressure in obese children through ambulatory blood pressure monitoring (ABPM), especially in the developing world. This study aims to characterize ambulatory blood pressure in obese children and to explore feasibility of using office BP that will predict ambulatory hypertension. Methods:In the present study, 55 children with a body mass index (BMI) in the ≥95th percentile for age and sex were enrolled in a tertiary care hospital and underwent 24 h of ABPM and detailed biochemical investigations. Results:Ambulatory hypertension was recorded in 14/55 (25.5%; white coat hypertension in 17/29 (58.6%) and masked hypertension in 2/26 (7.69%). For office SBP percentile the area under curve (AUC) was 0.773 (95% CI: 0.619-0.926, p = 0.005) and for office DBP percentile the AUC was 0.802 (95% CI: 0.638-0.966, p = 0.002). The estimated cut offs (Youden's index) for office blood pressure which predicts ambulatory hypertension in obese children were the 93rd percentile for systolic BP (sensitivity-67% and specificity-78%) and the 88th percentile for diastolic BP (sensitivity-83% and specificity-62%). Conclusion:Ambulatory blood pressure abnormalities are highly prevalent among children with obesity. Office blood pressure did not accurately predict ambulatory hypertension. More than half of the children labeled as "hypertension" on office blood pressure measurement in the study were diagnosed to have white coat hypertension (WCH), thus emphasizing the role of ABPM for evaluation of WCH before the child is subjected to detailed investigations or started on pharmacotherapy.
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Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Abhijit P Pakhare
- Department of Community & Family Medicine, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Priya Gogia
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Shikha Jain
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Nayan Gupta
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Sudhir K Goel
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
| | - Rajesh Malik
- Department of Radio-diagnosis, All India Institute of Medical Sciences (AIIMS) Bhopal, Bhopal, India
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Goyal A, Pakhare AP, Bhatt GC, Choudhary B, Patil R. Association of pediatric obstructive sleep apnea with poor academic performance: A school-based study from India. Lung India 2018; 35:132-136. [PMID: 29487248 PMCID: PMC5846262 DOI: 10.4103/lungindia.lungindia_218_17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pediatric obstructive sleep apnea (OSA) is a highly prevalent but often neglected disorder. There is paucity of reports on the prevalence of pediatric OSA from India. This study was done to estimate the prevalence of OSA in school children aged 5-10 years and its association with academic performance. METHODOLOGY This school-based cross-sectional epidemiological study was conducted from July 2015 to November 2015. A questionnaire seeking information on sociodemographic variables, school performance, sleeping pattern, and a validated 22-item pediatrics sleep-related breathing disorder (SRBD) scale was distributed to 1820 pupils in three primary schools. The prevalence of OSA (defined as SRBD score >33%) was reported as proportion and its 95% confidence interval (CI). RESULTS We received 1520 questionnaires out of 1820 distributed and of which 1346 were complete and were analyzed. The prevalence of OSA among children in our study was 9.6% (95% CI: 8.1%-11.7%). On multivariate analysis, working mother (adjusted odds ratio [OR]: 1.8; 95% CI: 1.2-2.7), sleep bruxism (adjusted OR: 1.7; 95% CI: 1.1-2.6), and sleep talking (adjusted OR: 3.0; 95% CI: 1.9-4.7) were found to be independently associated with OSA. Students with positive SRBD were more prone to nocturnal enuresis (NE) (OR 3.48; 95% CI 2.27-5.26) and poor academic performance in all subjects. CONCLUSION OSA is highly prevalent (9.6%) in Indian children. OSA is associated with NE and poor academic performance in all subjects. This study found association of maternal occupation and OSA which needs to be confirmed in larger studies.
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Affiliation(s)
- Abhishek Goyal
- Department of Pulmonology and Sleep Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Abhijit P Pakhare
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bharat Choudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Rajesh Patil
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Patel B, Tiwari A, Dubey SRK, Bhatt GC, Tiwari P, Bhan BD. Takayasu arteritis presenting with malignant hypertension; a rare manifestation of a rare disease: a case report and review of the literature. Trop Doct 2016; 47:60-63. [PMID: 27216226 DOI: 10.1177/0049475516648062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Takayasu arteritis (TA) is a chronic inflammatory and obliterative disease of large vessels, which mainly affects the aorta and its major branches. TA can lead to renal failure and renovascular hypertension in 60% of patients; it is rare in children aged <10 years and, more rarely, it presents with malignant hypertension in the paediatric age group. Here we present a case of 9-year-old boy with TA who presented with malignant hypertension and required surgical intervention to control the blood pressure. Subsequently, his medications were titrated using 24 h ambulatory blood pressure monitoring (ABPM) and is doing well on follow-up.
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Affiliation(s)
- Bhupeshwari Patel
- Senior Resident, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Astha Tiwari
- Assistant Professor, Department of Paediatrics, Chirayu Medical College, Bhopal, Madhya Pradesh, India
| | - Shiv Ram Krishna Dubey
- Senior Resident, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Assistant Professor, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Punit Tiwari
- Department of Urosurgery, Chirayu Medical College, Bhopal, Madhya Pradesh, India
| | - Bhavna Dhingra Bhan
- Assistant Professor, Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Bhatt GC. Enuresis and Sleep Disorders in Children. Indian Pediatr 2015; 52:995. [PMID: 26615359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, AIIMS, Bhopal, Madhya Pradesh, India.
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Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
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Bhatt GC. Commentary. J Neurosci Rural Pract 2013; 4:S44-5. [PMID: 24174799 PMCID: PMC3808061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India,Address for correspondence: Dr. Girish C. Bhatt, Flat no. 4012. Type IV, Residential Complex, AIIMS, Bhopal, India. E-mail:
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Bhatt GC. Comments on 'acute myocarditis in vivax malaria: an extremely rare complication'. Trop Doct 2013; 43:128. [PMID: 23846993 DOI: 10.1177/0049475513495020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Midala TA, Lege-Oguntoye L, Werblinska B, Bhatt GC. In-vivo sensitivity of Plasmodium falciparum to chloroquine in Zaria, Nigeria. J Trop Med Hyg 1988; 91:9-11. [PMID: 3279222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In 33 children with confirmed Plasmodium falciparum malaria, the WHO Extended Field Test was employed to test the sensitivity of the parasite to chloroquine in Zaria urban area. No evidence of resistance to the drug was found. In 82% of the patients parasitaemia had disappeared within 3 days, while the remaining 18% were parasite negative on day 4 or 5. The mean parasite clearance time was calculated as 3.45 +/- 1.23 days. The results suggest that chloroquine sensitivity of P. falciparum may be decreased in this part of Nigeria.
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Affiliation(s)
- T A Midala
- Department of Pharmacology, Ahmadu Bello University, Zaria, Nigeria
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