Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Development of a hybrid undergraduate portfolio for the AETCOM module

Background

A structured Attitude Ethics and Communication (AETCOM) module for undergraduates exists. For ensuring that the module achieves what it is intended to achieve, there was a felt need to develop a learning portfolio with an emphasis on reflections and with a scope for assessment.

Methods

The AETCOM module by NMC has laid out objectives, lesson plans, and case-based scenarios. Hybrid portfolio development was necessary to align the sessions to the objectives and lesson plans and to help students capture their learning process with self-reflection, and at the same time, ensure the scope of assessment of these activities. Hence, writing reflections was considered the most important step. Measures were taken to train students in writing reflections, and faculty development workshops were also conducted. An evaluation was done using Kirkpatrick model level I-III using student's feedback form, scores of rubric matrix for assessment of reflections and one-on-one interaction with students by trained faculty. Faculty perspectives on portfolio development were collected.

Results

A significant improvement in students' self-assessment scores on AETCOM module was seen (p <0.05). An assessment of reflections using a rubric matrix showed that all the students reached at least grade B by the end of three months. More than 90% of faculty members felt that the faculty is vital for assessing AETCOM.

Conclusion

The development of a hybrid portfolio for AETCOM requires faculty development and special sessions for students on writing reflections. The hybrid portfolio provides the learner to self reflect, and a rubric matrix can be used to assess reflections.

Improved sleep, cognitive processing and enhanced learning and memory task accuracy with Yoga nidra practice in novices

Complementary and Alternative medicine is known to have health benefits. Yoga nidra practice is an easy-to-do practice and has shown beneficial effects on stress reduction and is found to improve sleep in insomnia patients. Effect of yoga nidra practice on subjective sleep is known but its effect on sleep and cognition objectively is not documented. The aim of the study was to study the effect of yoga nidra practice on cognition and sleep using objective parameters. 41 participants were enrolled, and baseline sleep diary (SD) collected. Participants volunteered for overnight polysomnography (PSG) and cognition testing battery (CTB) comprising of Motor praxis test, emotion recognition task (ERT), digital symbol substitution task, visual object learning task (VOLT), abstract matching (AIM), line orientation task, matrix reasoning task, fractal-2-back test (NBACK), psychomotor vigilance task and balloon analog risk task. Baseline CTB and after one and two weeks of practice was compared. Power spectra density for EEG at central, frontal, and occipital locations during CTB was compared. Repeat SD and PSG after four weeks of practice were done. After yoga nidra practice, improved reaction times for all cognition tasks were seen. Post intervention compared to baseline (95%CI; p-value, effect size) showed a significant improvement in sleep efficiency of +3.62% (0.3, 5.15; p = 0.03, r = 0.42), -20min (-35.78, -5.02; p = 0.003, d = 0.84) for wake after sleep onset and +4.19 μV2 (0.5, 9.5; p = 0.04, r = 0.43) in delta during deep sleep. Accuracy increased in VOLT (95% CI: 0.08, 0.17; p = 0.002, d = 0.79), AIM (95% CI: 0.03, 0.12; p = 0.02, d = 0.61) and NBACK (95% CI: 0.02, 0.13; p = 0.04, d = 0.56); ERT accuracy increased for happy, fear and anger (95% CI: 0.07, 0.24; p = 0.004, d = 0.75) but reduced for neutral stimuli (95% CI: -0.31, -0.12; p = 0.04, r = 0.33) after yoga nidra practice. Yoga Nidra practice improved cognitive processing and night-time sleep.

Correlation of renal length with anthropometric and demographic data in healthy children: A prospective cross sectional study

Background

Renal size is an important parameter in the assessment of a child with renal disease. Renal size can be estimated by measuring renal length, renal volume, and cortical volume or thickness. Renal length depends on different factors, which include size, body mass index and gender. Ultrasonography is useful, non-invasive and easily available method for reliably performing the measurement of kidney length. This study was conducted to find out correlation between renal length and age and anthropometric variables in healthy children. This prospective cross sectional study was carried out with the following objectives: (a) To determine the anthropometric variable that correlated best with renal length in healthy children. (b) To develop a nomogram for renal length in healthy children.

Methods

Five hundred healthy children were included in this study. Sonographic assessment of renal length was performed using real time mechanical sector scanner with 5 MHz and 8 MHz frequency. The renal length was correlated with somatic parameters like age, weight, height, body surface area and body mass index. Regression equations were derived for each pair of dependent and independent variables.

Results

We performed the measurement of renal length in 500 healthy children. In our series, renal measuring parameters showed a good correlation with studied body parameters, height having the best correlation. Data from left and right kidneys are shown separately since there was small but statistically significant difference between them. Based on our study, using the height of the child, renal length may be calculated by using following equation: Left renal length (cm) = 0.052 × height (cm) + 1.042, Right renal length (cm) = 0.052 × height (cm) + 0.867.

Conclusions

This study provides values of renal length (mean ± 2SD) in normal Indian children and its correlation with body parameters. Renal length may be easily calculated by derived linear regression equation. Nomograms of renal length with respect to age and height have been formulated. Renal Length was found to correlate best with height of the child.

COVID-19 Pandemic in Malegaon: SUTRA over the Three Waves

Over the past two years, the COVID-19 pandemic has seen multiple waves with high morbidity and mortality. Lockdowns and other prompt responses helped India's situation become less severe. Although Malegaon in the Indian state of Maharashtra has a high population density, poor hygienic standards, and oppositional local community views toward national pandemic addressing measures, it is nevertheless reasonably safe. To understand the possible reasons serosurvey was conducted to estimate the anti-SARS-CoV-2 neutralizing antibody levels in the Malegaon population. Also, we did SUTRA mathematical modeling to the Malegaon daily data on COVID-19 attributable events and compared it with the National and state level. The case fatality rate (CFR) in Malegaon city for the first, second, and third waves was 3.25%, 2.25%, and 0.39%, respectively. The crude death rate (CDR) for Maharashtra ranked first for the initial two waves and India for the third wave. Malegaon, meanwhile, finished second in the first two waves but fared best in the third. The Vaccination coverage for the first dose before the second wave was only 0.34% but had risen to 64.46% by 12 Oct 2022. By then, the second and booster dose coverage was 27.55% and 2.38%, respectively. Serosurvey did between 12 and 18 Jan 2022 showed a 93.93% anti-SARS-CoV-2 neutralizing antibody presence. SUTRA modeling elucidated the high levels of antibodies due to the pandemic-reach over 102% by the third wave. The serosurvey and the model explain why the pandemic severity in terms of duration and CFR during the subsequent waves, especially third wave, was milder compared to the first wave in spite of low vaccination rates.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12088-023-01096-3.

Comparative analysis of blind vs real-time ultrasound-guided pediatric renal biopsies: A cross-sectional study

Background

Renal biopsy has a definite role in the management of pediatric kidney diseases. Most centers have given up the earlier practice of performing blind biopsy using Tru-Cut needle and started doing real time ultrasound-guided renal biopsy with an automated spring-loaded gun, which has become standard of care in the last decade or so.

Methods

We performed a cross-sectional analysis of the pediatric biopsies conducted at our center over the years by both methods to evaluate whether ultrasound-guided renal biopsy with a disposable automated spring-loaded gun was superior to blind biopsy with a disposable needle of the same size in terms of reduction of complications and improving the yield. We also reviewed the indications and the histopathological diagnosis of pediatric renal biopsies at our center.

Results

A total of 45 native kidney biopsies were performed blind and 48 ultrasound-guided biopsies using the curvilinear probe (frequency 3-5 Hz) of GE Logiq P3 ultrasound machine with disposable spring-loaded automated guns. There was a significant increase in the yield of biopsy in terms of the number of glomeruli per pass. A significant increase in the mean number of glomeruli was noted when a biopsy was performed under ultrasound guidance (P < 0.0001). Gross hematuria was significantly reduced as compared to the earlier biopsies done blind i.e., without ultrasound (P ¼ 0.03). Nephrotic syndrome was the commonest indication for biopsy in our patients during both time periods studied. The most common histopathological diagnosis was MesPGN among the children who underwent kidney biopsy from 2005 to 2007, while Minimal Change Disease (MCD) and Focal Segmental Glomerulosclerosis (FSGS) were most frequently reported.

Conclusion

Ultrasound guided kidney biopsies in pediatric age group have significant reduction in incidence of post gross hematuria and significant increase in the mean number of glomeruli per pass.

Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Background

Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality. Regular simulation-based training modules are conducted in our institute for health-care providers. The objective of this study was to assess the final-year medical students on their subjective improvement in the management of PPH after an off-site simulation-based training which was conducted after a conventional lecture.

Methods

A survey was administered on medical students and their subjective retrospective analysis of both pre and post off-site simulation was collected. The survey was analyzed, and results were formulated.

Results

Forty-six students completed the survey. Although students felt their confidence level in enumerating the steps in management of PPH less than 50% before the drill, it increased to 70% after the drill. The confidence of the students in carrying out the procedures of PPH also increased. The results showed a considerable subjective improvement in skill and cognitive enhancement after an off-site simulation-based training. There was a significant improvement in the pre and postsimulation training scores in the test. The faculty felt that there was an enhancement in learning after the simulation training.

Conclusion

Off-site simulation of an emergency condition improves both knowledge and skill in students.

Gestational Age-Specific Nomogram of Transcutaneous Bilirubin in First 120 h of Life for Term and Late Preterm Indian Neonates

OBJECTIVE

To create a nomogram based on transcutaneous bilirubin values (TCB) in first week of life for term and late preterm (>34 weeks) neonates.

METHODS AND DESIGN

Prospective longitudinal study.

SETTING

Four tertiary-care teaching hospitals (one each in eastern and southern India, two in northern India) between February 2019 and March 2020.

PARTICIPANTS

A total of 2492 term and late preterm (>34 weeks) neonates.

INTERVENTION

Bilirubin was measured by transcutaneous bilirubinometer (Drager JM-105, Germany) in all neonates in pre-specified times of the day, 12 hourly every day since birth till discharge between 48 and 72 h, and data were recorded in epochs of 6 hourly intervals. Post-discharge, all neonates were called for review in next 48 h.

OUTCOME MEASURES

Primary-TCB in first week of life. Secondary-factors having significant association with significant hyperbilirubinaemia requiring phototherapy.

RESULTS

Total of 2492 neonates (males 1303 and female 1189), with a total of 14 162 TCB recordings were analysed and mean hourly bilirubin (TCB) at hourly intervals till 120 h and then daily bilirubin values on Days 6 and 7 were tabulated. We have constructed hour-specific bilirubin nomogram with percentiles as per gestational age in term and near-term Indian neonates till 120 h of life. Amongst the known risk factors, delayed cord clamping, primipara and breastfeeding jaundice had significant association for hyperbilirubinaemia needing phototherapy.

CONCLUSIONS

We have created gestation-specific nomogram of TCB levels in 6 hourly intervals for the first 120 postnatal hours, obtained from a large predominantly breast fed healthy, term and near-term Indian neonates.

National exit test: The medical faculty perspective-A pilot study

Background Implementation of the exit examination for medical graduates in India has been debated for many years. The national exit test (NEXT), under the construct of the National Medical Commission Act, would serve two purposes: first, it will be a common exit/licentiate examination for all Indian medical graduates, and second, it will be a test for postgraduate selections for all specialties. There has been no research or evidence on stakeholders' opinion on this test. We aimed to assess the perspective of medical faculties, nationwide, regarding the implementation of NEXT. Methods We conducted a nationwide, cross-sectional, questionnaire-based pilot survey. The Google survey form with close- and open-ended questions was forwarded via email and WhatsApp to various groups. Results Two hundred and forty-five medical teachers participated, of which 35.9% were from Gujarat, 44.9% were working in government colleges, 91.43% had MD/MS as the highest professional degree, 50% had >15 years of experience and were from different medical specialties. The majority felt that the NEXT examination was a positive step, 82.5% suggested that a national selection/testing authority should conduct it, 36.3% suggested having the test after internship while 32.7% expected some weightage for each year of the medical programme, and 84.1% agreed that all the learning domains should be assessed by various strategies. Discussion Faculties welcomed the NEXT examination under a national testing authority. The necessity of this examination is to have uniform standards and quality for medical graduates irrespective of their institutes. Assessment of all the domains will make the Indian medical graduate more competent for the job or residency programmes.

Comparison of a Voiding Diary With Clinical Management Tool As an Outpatient Screening Tool for Childhood Functional Voiding Disorders

OBJECTIVE

To study the agreement of questionnaire-based assessment with voiding diary for differentiating primary mono-symptomatic nocturnal enuresis from voiding disorder in children.

METHOD

Children 5-12 years old with bedwetting after exclusion of secondary enuresis were enrolled and parents filled a clinical management tool (CMT) questionnaire and a 48-hours voiding diary. Point prevalence and agreement of classification as primary mono-symptomatic nocturnal enuresis or voiding disorder were compared.

RESULTS

Of 1276 children screened, 143 (11.2%) reported enuresis. Of 100 (82 males) children finally analyzed, constipation and positive family history occurred in 14% and 37%, respectively. Questionnaire-based assessment and voiding diary identified 65% and 71%, respectively as voiding disorder [Cohen's kappa 0.542 (95%CI: 0.367-0.717)]. Discordance of classification was noted in 20%. Voiding diary identified additional 7% cases of voiding disorder.

CONCLUSIONS

While CMT and voiding diary have moderate agreement, voiding diary should be used for cases screened negative by a questionnaire-based tool.

Study of psychological effects of deployment at extreme high altitude area on soldiers

Background

The Indian Armed Forces are fighting the battle at extreme High Altitude, the most inhospitable terrain in the world, for the last thirty five years. The stress of being isolated under harsh environmental conditions on a daily basis can have an adverse effect on their mind. However, so far, no study has been undertaken to assess the psychological effects of deployment at extreme High Altitude.

Methods

Three hundred thirty-four troops selected for deployment were initially evaluated using the General Health Questionnaire-12 (GHQ-12) and Armed Forces Medical College Life Events Scale (AFMC LES) as screening tools to assess mental health status after obtaining ethical clearance and informed consent. On deinduction after a deployment for more than three months, they were reassessed. The data collected were statistically analysed.

Results

As per GHQ-12 evaluation, after the deployment score increased from 0.2574 to 0.9162, but remained lower than the 'caseness' level of 2. Among the 79 troops with a score of 2 and more, the majority were married and had past history of tenures at high-altitude areas. There was statistically significant increase in the AFMC LES scores also on deployment.

Conclusion

Deployment at extremely high-altitude areas for even three months produces significant psychological morbidity among troops.

Health technology assessment of telemedicine applications in Northern borders of India

BACKGROUND

Economic evaluations of health technology help to decide which interventions are to be continued and which are to be terminated. In the Armed Forces, the provision of efficient medical services requires meticulous planning for optimal utilization of scarce resources. We report a cost analysis of telemedicine and air transportation of casualties, and attempt to identify the strengths, weaknesses, opportunities and threats of telemedicine services.

METHODS

The costs incurred in telemedicine were compared with the cost of air evacuation. A qualitative assessment of telemedicine was undertaken through in-depth interviews with the hospital authorities and focused group discussions with medical officers and paramedical staff.

RESULTS

34.2% of casualties could successfully be stabilized on-site using available healthcare resources with the peripheral hospitals. 18 casualties were managed at the periphery on-site by teleconsultations each year, averting air-transportation efforts. Estimated cost savings achieved in the initial management of casualty by teleconsultation was Rs. 146,111 per case. The strengths of telemedicine are knowledge updation, faster decision making, improved pre-hospital care and improved confidence in case management.

CONCLUSION

The reduction in air efforts and remote management of casualties make a substantive case for scaling up telemedicine interventions.

Modelling the spread of SARS-CoV-2 pandemic - Impact of lockdowns & interventions

BACKGROUND & OBJECTIVES

To handle the current COVID-19 pandemic in India, multiple strategies have been applied and implemented to slow down the virus transmission. These included clinical management of active cases, rapid development of treatment strategies, vaccines computational modelling and statistical tools to name a few. This article presents a mathematical model for a time series prediction and analyzes the impact of the lockdown.

METHODS

Several existing mathematical models were not able to account for asymptomatic patients, with limited testing capability at onset and no data on serosurveillance. In this study, a new model was used which was developed on lines of susceptible-asymptomatic-infected-recovered (SAIR) to assess the impact of the lockdown and make predictions on its future course. Four parameters were used, namely β, γ, η and ε. β measures the likelihood of the susceptible person getting infected, and γ denotes recovery rate of patients. The ratio β/γ is denoted by R0 (basic reproduction number).

RESULTS

The disease spread was reduced due to initial lockdown. An increase in γ reflects healthcare and hospital services, medications and protocols put in place. In Delhi, the predictions from the model were corroborated with July and September serosurveys, which showed antibodies in 23.5 and 33 per cent population, respectively.

INTERPRETATION & CONCLUSIONS

The SAIR model has helped understand the disease better. If the model is correct, we may have reached herd immunity with about 380 million people already infected. However, personal protective measures remain crucial. If there was no lockdown, the number of active infections would have peaked at close to 14.7 million, resulted in more than 2.6 million deaths, and the peak would have arrived by June 2020. The number of deaths with the current trends may be less than 0.2 million.

M3: The military medicine module: A focussed competency-based program

BACKGROUND

Military medicine is a unique and specific field for the armed forces doctors providing skill-based training on military specific injuries and diseases arising due to the unique occupational conditions. The current study retrospectively studied the planning and implementation of the military medicine module which was carried out with the aim of imparting the requisite skills to military doctors.

METHODS

The study was a qualitative research, carried over two years, 2017-2019. The study population included two batches of recently graduated medical doctors about to be commissioned . The methodology included needs assessment and gap analysis which was carried out by consulting experts from the tri services. Feedback was taken by medical education experts from both the batches using surveys, and modifications were done after brainstorming with experts keeping feedback in mind.

RESULTS

There was an improvement in the rating scores and an improved performance by participants was seen in the competencies.

CONCLUSION

In conclusion the module was developed and implemented keeping in mind the important skills that military physicians need to learn through training as these are not been taught in any educational syllabus. To achieve such skills and capabilities, gap analysis is essential and programs should be implemented keeping scope for modification depending on the feedback after brainstorming. Feedback remains important in development of such modules and hence should be collected anonymously.

Challenges faced in establishing a dedicated 250 bed COVID-19 intensive care unit in a temporary structure

An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. While this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. Consequently, the establishment of an ICU requires rigorous design and planning, a process that can take months to years. However, the Coronavirus disease-19 (COVID-19) epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. At the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. This narrative review describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.

A Crossover Comparative Study to Assess Efficacy of 5% vs. 20% Albumin in the Treatment of Anasarca in Children with Idiopathic Nephrotic Syndrome

Introduction: Co-administration of albumin and furosemide has shown better response than furosemide alone in managing anasarca among children with nephrotic syndrome. There are different concentrations of albumin available. The aim of this study was to compare diuretic response to co-administration of either 5% or 20% albumin with furosemide in these children. Methods: It was a crossover randomised trial conducted on children with nephrotic syndrome with moderate to severe oedema at a tertiary care centre. They were  randomised to two groups; Group A (n = 14) received 5% albumin along with furosemide in midway followed by 20% albumin after washout period of 48 hrs and group B (n = 10) received albumin vice versa. Baseline and post therapy vitals, fluid intake, urine output and biochemistry were noted. Primary outcomes were increase in urine output and reduction in weight following co-administration of albumin with furosemide. For analysis of primary outcomes, two interventional arms were formed; group I (5% Albumin co-administered with furosemide) and group II (20% albumin co-administered with furosemide). Results: Total children were 24 in each arm i.e. group I and II. Eighteen (75%) were males. Mean (range) age at enrolment and duration of illness were 55.3 (15 - 144) and 18.6 (1 - 120) months respectively. Mean difference (SD) in urine output were 1.52 (1.11) and 1.66 (0.95) ml/kg/hr (p = 0.12) and mean percentage weight loss were 2.25% (2.12) and 3.68% (3.84) in group I and II respectively (p = 0.64). On further comparing, urine output was significantly better when 5% albumin was co-administered with furosemide during first period than in second period. Conclusions: Co-administration of either 5% or 20% albumin with furosemide is equally safe and effective in increasing urine output in children with anasarca.

Weight of Schoolbags Among Indian Schoolchildren in Pune and Hyderabad

OBJECTIVE

This study was done to determine proportion of children carrying heavy school bags and to compare new guidelines issued by Government of India on school bag weight limit, based on class of the child with previous guidelines based on child's weight.

METHODS

A cross-sectional study was done among students of schools from two cities of India - Pune and Hyderabad. Weight of school bag of 1321 children was measured and classified as 'heavy' or 'normal' based on existing as well as new guidelines. Agreement between two guidelines was also calculated.

RESULTS

In our study, 722 (77.2%) out of 935 students from class 1-10 were found to be carrying 'heavy' school bags. Kappa coefficient for agreement between two guidelines was 0.55 (0.47,0.60) indicating moderately strong agreement.

CONCLUSIONS

Large proportion of school children are carrying school bags with weight beyond permissible limits. There is a need for all stake holders to take steps to reduce weight of school bags.

Managing Children With Renal Diseases During the COVID-19 Pandemic

The coronavirus outbreak is a rapidly evolving pandemic, placing unprecedented strain on health-care systems. COVID-19 presents challenges for management of children with renal diseases, especially those receiving long-term immunosuppressive medications, including renal transplant recipients and those with chronic kidney disease and acute kidney injury requiring dialysis. Our preparedness for managing this vulnerable group of children is the need of the hour. The purpose of this article is to provide guidance to caregivers and health care personnel involved in management of children with renal diseases and to ensure patient well-being, while protecting staff from infection.

Measles, mumps, and rubella: A cross-sectional study of susceptibility to vaccine-preventable diseases among young people in India

BACKGROUND

Global elimination of vaccine preventable diseases, such as measles, mumps and rubella is a priority. Many countries have reported diminishing of antibody titres against these diseases among young population as immunization coverage of adolescents and adults in not monitored. The objective of this study was to determine the susceptibility against measles, mumps and rubella among young adults.

METHODS

In this cross-sectional study serological evidence of susceptibility to measles, mumps and rubella was determined by qualitative detection of IgG antibody titres by commercially available enzyme linked florescence assay (VIDAS, bioMerieux) in serum samples young adults.

RESULTS

A total of 335 young individuals (mean age: 20.54 ± 1.37 years) participated voluntarily between May 2017 to September 2018, of which 183 (54.63%) were males. Seroprotection against measles, mumps and rubella were 87.16%, 82.69% and 79.10% respectively.

CONCLUSION

Serological surveillance is important to monitor immune status in population. Susceptibility of young adults to measles, mumps, and rubella indicates need for booster vaccination. With the recent launch of measles-rubella vaccination campaign in India, country specific data will be required to plan periodicity of such campaign, which in turn would be based on accumulation of susceptible individuals in a community. Lastly, inclusion of mumps vaccine in the national universal immunization program needs consideration.

Can microRNA profiles predict corticosteroid responsiveness in childhood nephrotic syndrome? A study protocol

INTRODUCTION

In last few years, several studies have revealed the remarkable stability of extracellular microRNAs (miRNAs) circulating in the blood or excreted in the urine and underscored their key importance as biomarkers of certain diseases. Since miRNA in urinary sediment is relatively stable and easily quantified, it has the potential to be developed as a biomarker for disease diagnosis and monitoring. Identification of serum and urinary levels of certain miRNAs may assist in the diagnosis and assessment of disease activity in patients with nephrotic syndrome (NS). The global expression profile of miRNAs in childhood NS in Indian population remains unknown. Hence, further research is warranted in this area. This study seeks to prospectively evaluate whether a multipronged multiomics approach concentrating on microRNA expression profiles in children with NS vis-a-vis normal healthy children is discriminant enough to predict steroid responsiveness in childhood NS.

METHODS AND ANALYSIS

In this prospective multicentric cohort study, subjects will be recruited from general paediatric and paediatric nephrology outpatient departments (OPDs) in tertiary care level referral hospitals. Age-matched and sex-matched healthy individuals with normal renal function (as assessed by normal serum creatinine and normal ultrasound of kidneys, ureter and bladder) in 1:1 ratio between study and control groups will be recruited from among the healthy siblings of children presenting to the OPDs. Differential microRNA expression profiles in urine and serum samples of children with steroid-sensitive NS (SSNS) and steroid-resistant NS (SRNS) with healthy children will be compared in a two-phased manner: a biomarker discovery phase involving pooled samples across SSNS, SRNS and healthy siblings analysed in triplicate using next-generation sequencing, slide microarray and quantitative reverse transcriptase PCR (qRT-PCR) arrays covering human miRNome followed by a validation phase with customised qRT-PCR primers based on the concordance in the discovery phase differential expression profiles and bioinformatics analysis.

ETHICS AND DISSEMINATION

The study is funded after dueInstitutional Ethics Committee (IEC) clearance, and results will be available as open access.

Rejected but not dejected: Dealing with an unfavourable decision on a scientific manuscript

Unfavourable decisions and rejections on submitted manuscripts are not uncommon in scholarly publications. Rejection in a particular journal need not be viewed as end of all hopes for aspiring authors. Substantial number of rejected manuscripts find their final place in one or the other journal after suitable revision. As an author, it is extremely important to be familiar with common reasons for unfavourable decision/rejection in order to prevent them or to find solutions.

Cardiovascular outcomes of Nephrotic syndrome in childhood (CVONS) study: a protocol for prospective cohort study

BACKGROUND

Nephrotic syndrome (NS) is characterized by dyslipidemia which is a well-known risk factor for atherogenesis. Atherosclerosis in childhood is mostly subclinical and endothelial dysfunction is known to precede this. Evidence for screening for endothelial dysfunction and cardiovascular risk factors and early identification of premature onset of atherosclerosis in childhood NS remains tenuous in the absence of well-designed prospective studies addressing cardiovascular comorbidity in NS. The objective of our study is to examine endothelial dysfunction and short-term cardiovascular outcomes in a carefully phenotyped cohort of patients with Nephrotic syndrome as compared to healthy controls.

METHODS

In a multi-centric prospective cohort study, 70 Steroid Resistant NS (SRNS), 70 Steroid Sensitive (SSNS) patients along with 70 Healthy Controls are being recruited. After a baseline assessment of functional and structural status of heart (2D Echocardiography), arteries (Carotid Doppler and Intima Media Thickness measurements) and microcirculation [a combination of 2D Echocardiography, Laser Doppler Flowmetry (LDF) and Brachial Artery Flow mediated dilation (FMD) and Nail Fold Capillaroscopy (NFC)], the patients are being investigated for endothelial dysfunction. Venous blood sample (15 ml) is being collected for routine investigations and assay of biochemical endothelial markers through Flow Cytometry. The patients will be followed up at 12 months and 24 months after the recruitment to look for any change from baseline period.

DISCUSSION

This study will able to provide a better understanding of the epidemiology of endothelial dysfunction and associated subclinical cardiovascular co-morbidity in childhood NS. Findings on characterization of prevalence of endothelial dysfunction and subclinical markers may be used to design future randomized controlled trials for evaluating the efficacy of preventive and therapeutic interventions in reducing the incidence of cardiovascular disease.

Health care for children in Indian Armed Forces

Children of Armed Forces personnel constitute 33% of the clientele dependant on our healthcare. Various child health indicators and immunization coverage of Indian Armed Forces children is better than the national figures. With improved patient care, it has been observed that the morbidity and mortality pattern of diseases affecting the children of Armed Forces personnel has shown a change from infectious diseases in the past to more of chronic complex disorders at present. Hospital admissions of children in military hospitals due to nutritional and infectious diseases have reduced and constitute only around 21% of all paediatric hospital admissions. Various factors responsible for this shift are preventive health measures (antenatal care, immunization), Active promotion of health (baby friendly hospital concept, Well baby clinic) curative health services (outpatient services, in-patient care, specialty care, supportive Care) and supportive care-reaching beyond like ASHA schools. Presently, we need to handle, life style diseases like obesity, mental stress, teach coping mechanisms for common stressors such as parental separation, family reunification, parental loss, behavioral problems, diseases other than infectious diseases requiring super specialty care. The challenge lies in planning the road ahead for these children and adolescents ensuring a life-course approach.

Bed wetting - silent suffering: an approach to enuresis and voiding disorders in children

Bed wetting or nocturnal enuresis is a common problem among children. It is either monosymptomatic or may be associated with a voiding disorder. Many factors may contribute towards enuresis such as developmental delay, heredity, inappropriate nocturnal anti diuretic hormone secretion and reduced bladder capacity. Any child presenting with bed-wetting should be evaluated for any underlying bladder dysfunction before labeling as monosymptomatic enuresis. The evaluation consists of structured bowel and bladder history, detailed clinical examination, frequency volume record and appropriate investigations. The frequency volume diary is an indispensible component of evaluation and helps in establishing diagnosis and tailoring therapy. The treatment of monosymptomatic enuresis consists of positive psychological support, alarms and medication (desmopressin/ anticholinergics/ imiprammine). Children with features of underlying bladder dysfunction, anatomical anomalies and neurological disorders should be referred to a pediatrician without delay. The outcome of therapy is usually rewarding but varies, depending on the underlying etiology, motivation, compliance and family support. The cure rates with alarms are better than with desmopressin in monosymptomatic enuresis. Timely and appropriate therapy yields better outcomes. Thus, a thorough, scientific and evidence based approach is essential in children presenting with bed-wetting.

Treatment with tacrolimus and prednisolone is preferable to intravenous cyclophosphamide as the initial therapy for children with steroid-resistant nephrotic syndrome

There are limited data on the relative efficacy and safety of calcineurin inhibitors and alkylating agents for idiopathic steroid-resistant nephrotic syndrome in children. To clarify this, we compared tacrolimus and intravenous cyclophosphamide therapy in a multicenter, randomized, controlled trial of 131 consecutive pediatric patients with minimal change disease, focal segmental glomerulosclerosis, or mesangioproliferative glomerulonephritis, stratified for initial or late steroid resistance. Patients were randomized to receive tacrolimus for 12 months or 6-monthly infusions of intravenous cyclophosphamide with both arms receiving equal amounts of alternate-day prednisolone. The primary outcome of complete or partial remission at 6 months, based on spot urine protein to creatinine ratios, was significantly higher in children receiving tacrolimus compared to cyclophosphamide (hazard ratio 2.64). Complete remission was significantly higher with tacrolimus (52.4%) than with cyclophosphamide (14.8%). The secondary outcome of sustained remission or steroid-sensitive relapse of nephrotic syndrome at 12 months was significantly higher with tacrolimus than cyclophosphamide. Treatment withdrawal was higher with cyclophosphamide, chiefly due to systemic infections. Compared to cyclophosphamide, 3 patients required treatment with tacrolimus to achieve 1 additional remission. Thus, tacrolimus and prednisolone are effective, safe, and preferable to cyclophosphamide as the initial therapy for patients with steroid-resistant nephrotic syndrome.

Revised statement on management of urinary tract infections

JUSTIFICATION

In 2001, the Indian Pediatric Nephrology Group formulated guidelines for management of patients with urinary tract infection (UTI). In view of emerging scientific literature, the recommendations have been reviewed.

PROCESS

Following a preliminary meeting in November 2010, a document was circulated among the participants to arrive at a consensus on the evaluation and management of these patients.

OBJECTIVES

To revise and formulate guidelines on management of UTI in children.

RECOMMENDATIONS

The need for accurate diagnosis of UTI is emphasized due to important implications concerning evaluation and follow up. Details regarding clinical features and diagnosis, choices and duration of therapy and protocol for follow up are discussed. UTI is diagnosed on a positive culture in a symptomatic child, and not merely by the presence of leukocyturia. The need for parenteral therapy in UTI in young infants and those showing toxicity is emphasized. Patients with aysmptomatic bacteriuria do not require treatment. The importance of bowel bladder dysfunction in the causation of recurrent UTI is highlighted. Infants with the first UTI should be evaluated with micturating cystourethrography. Vesicoureteric reflux (VUR) is initially managed with antibiotic prophylaxis. The prophylaxis is continued till 1 year of age in patients with VUR grades I and II, and till 5 years in those with higher grades of reflux or until it resolves. Patients and their families are counselled about the need for early recognition and therapy of UTI. Children with VUR should be followed up with serial ultrasonography and direct radionuclide cystograms every 2 years, while awaiting resolution. Siblings of patients with VUR should be screened by ultrasonography. Children with renal scars need long term follow up on yearly basis for growth, hypertension, proteinuria, and renal size and function.

Incidence of thrombocytopenia in the neonatal intensive care unit

BACKGROUND

Thrombocytopenia is the commonest haematological abnormality encountered in the neonatal intensive care unit (NICU). The incidence in neonates varies greatly, depending upon the population studied. The aim of the present study was to study the incidence of thrombocytopenia in the neonates admitted to the NICU.

METHOD

The study was carried out in 258 consecutive eligible neonates from August 2007 to August 2009. Neonates were placed in two risk groups for thrombocytopenia, viz. high risk and low risk, depending upon the presentation, maternal history and any antenatal/perinatal events. Platelet counts were done on the first, third and fifth day of admission and thereafter every 72 hours till counts were normal. Low counts were collaborated with a peripheral blood smear.

RESULTS AND CONCLUSION

The overall incidence of thrombocytopenia in the study group was 70% (182/258). The incidence in the high-risk group was 93.7% cases (134/143) and in the low-risk group was 41.7% (48/115). This difference was statistically significant. Factors associated with thrombocytopenia were sepsis, extreme low birth weight, intra-uterine growth restriction, birth asphyxia and pre-eclampsia in mothers. The most common severe bleeding manifestation was pulmonary haemorrhage. The overall mortality in babies with thrombocytopenia was 33% despite > 90% of these cases having received platelet transfusion. Of these pulmonary haemorrhage was the main cause of death in five cases. It is concluded that thrombocytopenia is very common in the NICU and should be actively looked for so that it can be managed appropriately.

Status Epilepticus in Children

Status epilepticus (SE) is a life-threatening emergency that requires prompt treatment, including basic neuroresuscitation principles (the ABCs), antiepileptic drugs to stop the seizure and identification of etiology. It results from an inability to normally abort an isolated seizure either due to ineffective inhibition, or due to abnormally persistent excessive excitation. Symptomatic SE is more common in younger children and the likely etiology depends on the age of the child. Treating the precipitating cause may prevent ongoing neurologic injury and facilitates seizure control. Benzodiapenes, phenytoin and phenobarbital form the mainstay of treatment. A systematic treatment regimen, planned in advance, is needed, including one for refractory status epilepticus (RSE). Patient education and home management of seizures is important to reduce the morbidity and mortality associated with SE.

Clinicopathological Spectrum of Renal Biopsies in Children

BACKGROUND

Renal biopsy has revolutionized the study of glomerular diseases. A retrospective analysis of 104 consecutive renal biopsies performed in children at a tertiary care referral centre over five years is presented.

METHODS

All the biopsies were performed non-ultrasound guided by a single consultant nephrologist. Trucut needles were used in the initial few years and a Magnum biopsy gun (Bard) over subsequent three years. There were 66 boys and 38 girls.

RESULT

A male predominance occurred in the older and younger patients. The male: female ratio was 2.2:1, 1:1, and 2.7:1 for the age groups below five years, 5-10 years and above 10 years respectively. All patients tolerated the biopsy well and success rate was 94%. There were minimal complications in the form of post biopsy haematuria (33.3%). Haematuria was mild in most of the cases and settled down within 24 hours. None required transfusion. However, 60% patients had mild discomfort in the form of local pain. There was no mortality, infection or renal loss. The most common indication for a kidney biopsy was nephrotic syndrome. Out of 104 biopsies, 85 were in children with nephrotic syndrome. The commonest primary renal pathology was mesangial proliferative glomerulonephritis (38%), minimal change disease (19%), focal segmental glomerulosclerosis (15%) and membranoproliferative glomerulonephritis (7%).

CONCLUSION

Renal biopsy is a safe procedure in experienced hands and the commonest indication for a biopsy in children remains nephrotic syndrome.

Growth in Children with Steroid Sensitive Nephrotic Syndrome

BACKGROUND

Nephrotic syndrome in children usually has an onset between 2-8 years of age and steroids form the mainstay of management. Therapy may affect growth in children with relapsing nephrotic syndrome. This study was carried out to correlate growth with the cumulative dose of steroids in children with steroid sensitive nephrotic syndrome (SSNS).

METHODS

Data of 35 children with SSNS was analysed retrospectively. They were divided into two groups. Group I received prednisolone only and Group II received levamisole and or cyclophosphamide in addition to steroids. Their heights were recorded at the time of inclusion and again one year later. The SD scores for age were determined. Growth rate as a change in the SD score over one year (Δ SD score) was correlated to the cumulative dose of steroids over the same period using the Pearson's correlation.

RESULT

There were 24 (68.6 %) boys and 11 (31.4 %) girls (M:F ratio 2.18:1) in the age group of 17 months to 11 years at inclusion. Group I constituted 19 (54.2 %) and Group II, 16 (45.8 %). Pearson's correlation coefficients for all children, Groups I and II were -0.341, -0.441 and -0.255 respectively indicating "Fair correlation". This indicates that as the cumulative dose of steroid increases the growth retardation becomes more apparent.

CONCLUSION

Growth retardation is proportional to the cumulative dose of steroids in children with SSNS.

Novel role of curcumin in the prevention of cytokine-induced islet death in vitro and diabetogenesis in vivo

BACKGROUND AND PURPOSE

Oxidative stress caused by cytokine exposure is a major cause of pancreatic islet death in vitro and of diabetogenesis. Antioxidant compounds may prevent cytokine-induced damage to islet cells. Hence, we studied the potential of curcumin, an antioxidant and anti-inflammatory compound, in vitro to protect islets against pro-inflammatory cytokines and in vivo to prevent the progression of diabetes induced by multiple low doses of streptozotocin (MLD-STZ).

EXPERIMENTAL APPROACH

Pancreatic islets from C57/BL6J mice were pretreated with curcumin (10 microM) and then exposed to a combination of cytokines. Islet viability, reactive oxygen species (ROS), NO, inducible NO synthase and NF-kappaB translocation were studied. Curcumin pretreated (7.5 mg kg(-1) day(-1)) C57/BL6J mice were given MLD-STZ (40 mg kg(-1)), and various parameters of diabetes induction and progression were monitored.

KEY RESULTS

Curcumin protected islets from cytokine-induced islet death in vitro by scavenging ROS and normalized cytokine-induced NF-kappaB translocation by inhibiting phosphorylation of inhibitor of kappa B alpha (IkappaBalpha). In vivo, curcumin also prevented MLD-STZ, as revealed by sustained normoglycaemia, normal glucose clearance and maintained pancreatic GLUT2 levels. Pro-inflammatory cytokine concentrations in the serum and pancreas were raised in STZ-treated animals, but not in animals pretreated with curcumin before STZ.

CONCLUSIONS AND IMPLICATIONS

Here, we have demonstrated for the first time that curcumin in vitro protects pancreatic islets against cytokine-induced death and dysfunction and in vivo prevents STZ-induced diabetes.

Recurrent urinary tract infection and functional voiding disorders

This study was carried out to determine the association of recurrent urinary tract infections with functional voiding disorders. Sixty eight children with suspected functional voiding disorders were prospectively evaluated clinically and by non-invasive urodynamics. Invasive urodynamics were carried out when indicated. Group I comprised 34 children with symptoms suggestive of functional voiding disorders and recurrent urinary tract infections (mean age 6.3+/-2 yr) and Group II comprised 34 children with symptoms suggestive of functional voiding disorders without recurrent urinary tract infections (mean age 6.7+/-2 yr). The underlying bladder abnormalities in Groups I and II were detrusor instability in 22 (64.7%) and 30 (88.2%), respectively (P>0.05) and dysynergic voiding in 10 (29.4%), and 1 (2.9%), respectively (P<0.05). Children with recurrent urinary tract infections are more likely to have a dysynergic voiding pattern than children presenting with other symptoms of functional voiding disorders.

Management of steroid sensitive nephrotic syndrome: revised guidelines

JUSTIFICATION

In 2001, the Indian Pediatric Nephrology Group formulated guidelines for management of patients with steroid sensitive nephrotic syndrome. In view of emerging scientific evidence, it was felt necessary to review the existing recommendations.

PROCESS

Following a preliminary meeting in March 2007, a draft statement was prepared and circulated among pediatric nephrologists in the country to arrive at a consensus on the evaluation and management of these patients.

OBJECTIVES

To revise and formulate recommendations for management of steroid sensitive nephrotic syndrome.

RECOMMENDATIONS

The need for adequate cortico-steroid therapy at the initial episode is emphasized. Guidelines regarding the initial evaluation, indications for renal biopsy and referral to a pediatric nephrologist are updated. It is proposed that patients with frequently relapsing nephrotic syndrome should, at the first instance, be treated with long-term, alternate-day prednisolone. The indications for use of alternative immunosuppressive agents, including levamisole, cyclophosphamide, mycophenolate mofetil and cyclosporin are outlined. The principles of dietary therapy, management of edema, and prevention and management of complications related to nephrotic syndrome are described. These guidelines, formulated on basis of current best practice, are aimed to familiarize physicians regarding management of children with steroid sensitive nephrotic syndrome.

Isolated islets in diabetes research

This review highlights some recent developments and diversified applications of islets in diabetes research as they are rapidly emerging as a model system in biomedical and biotechnological research. Isolated islets have formed an effective in vitro model in antidiabetic drug development programme, screening of potential hypoglycaemic agents and for investigating their mechanisms of action. Yet another application of isolated islets could be to understand the mechanisms of beta cell death in vitro and to identify the sites of intervention for possible cytoprotection. Advances in immunoisolation and immunomodulation protocols have made xeno-transplantation feasible without immunosuppression thus increasing the availability of islets. Research in the areas of pancreatic and non pancreatic stem cells has given new hope to diabetic subjects to renew their islet cell mass for the possible cure of diabetes. Investigations of the factors leading to differentiation of pancreatic stem/progenitor cells would be of interest as they are likely to induce pancreatic regeneration in diabetics. Similarly search for the beta cell protective agents has a great future in preservation of residual beta cell mass left after diabetogenic insults. We have detailed various applications of islets in diabetes research in context of their current status, progress and future challenges and long term prospects for a cure.