SpO2/FiO2 and PaO2/FiO2 for Predicting Intensive Care Admission in Wheezy Children: An Observational Study

OBJECTIVE

To determine the sensitivity of cut-off of SpO2/FiO2 (SF ratio) < 300 at hospital admission for predicting the need for admission in the pediatric intensive care unit (PICU) in wheezy children. Secondary objectives were to determine the sensitivity of cut-off of SF ratio < 300 for predicting in-hospital mortality and that of PaO2/FiO2 (PF ratio) < 200 for predicting intensive care admission and in-hospital mortality. We also ascertained the correlation between SF ratio and PF ratio in the above population.

METHODS

This observational study was conducted on 315 wheezy children aged 6 months to 12 years requiring admission in the pediatric emergency department. Oxygen saturation (SpO2) and fraction of oxygen in inspired air (FiO2) were recorded at admission while the partial pressure of oxygen (PaO2) was measured using arterial blood gas analysis performed within half an hour of admission. All children were managed as per protocol and followed up during hospital stay. Outcome was defined as the need for admission in the pediatric intensive care unit (PICU) or in-hospital mortality.

RESULTS

Cut -offs of SF ratio < 300 and PF ratio < 200 was able to determine the need PICU admission with a sensitivity of 97.30% and 62.16% respectively. The best cut-off of SF ratio for predicting PICU admission was < 178.79 [AUC (95% CI) 0.841 (0.767 - 0.914)], while that for PF ratio was < 201.81 [AUC (95< CI) of 0.849 (0.775 - 0.924)]. Cut-offs of < 300 for SF ratio and < 200 of PF ratio, were able to predict in-hospital mortality with sensitivity of 100<, but specificity of only 3.33< and 46.67<, respectively. There was only a fair correlation between SF ratio and PF ratio (r = 0.44, P < 0.001).

CONCLUSION

SpO2/FiO2 cut-off of < 300 had a good sensitivity in determining need for PICU admission. SF ratio has only a moderate correlation with PF ratio.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs

BACKGROUND

The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals.

OBJECTIVE

The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU.

MATERIALS AND METHODS

It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors.

RESULTS

 Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality.

CONCLUSIONS

Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Comparison of Emergency Severity Index Version 4 and Modified Pediatric Early Warning Score as Triage Models in the Pediatric Emergency of a Tertiary Care Public Sector Hospital

OBJECTIVE

To identify the sensitivity of emergency severity index (ESI) version 4 and modified pediatric early warning score (PEWS) in identifying high urgency patients.

METHODS

This cross-sectional study was conducted between November, 2019 and October, 2021 in the pediatric emergency department of tertiary hospital in Delhi. 250 patients aged 0-12 years coming to pediatric emergency on pre-decided days for health-related complaints were enrolled. These were assessed with both triage systems within 30 minutes of their arrival by a single researcher. 'High urgency' patients were defined as the ones who either required admission in pediatric ICU or died or had critical value of vital parameters as per institution protocol.

RESULTS

ESI version 4 had a sensitivity of 95.5%, specificity of 80.3%, with AUC of 0.879 (95%CI 0.834-0.925) in identifying high urgency patients at levels 1 and 2. Modified PEWS had comparatively lower sensitivity of 79.1%, specificity of 97.8%, with AUC of 0.885 (95%CI 0.825-0.994) in identifying high urgency patients at score of ≥3. The ESI version 4 was found to be a better predictor of admission than the modified PEWS, with a sensitivity of 98.2%. Both the scores were able to identify patients at risk of mortality with a sensitivity of 100%.

CONCLUSION

ESI version 4 is a better triage tool than modified PEWS in pediatric population in a tertiary care public hospital setting in this region.

A Quality Improvement Study to Improve Oxygen Prescription in the PICU of a Tertiary Care Centre in Delhi, India

Introduction Oxygen has been gravely misused since its inception as a therapeutic agent. There is a deficit of audits and baseline data for the Indian population, especially in the pediatric age group, which doesn't allow for standardization of protocols and guidelines. Objective Our study aimed at increasing valid prescription rates to 90% by implementation of quality improvement interventions, and assessing knowledge and perception of healthcare workers towards oxygen therapy. Methodology It followed a before-and-after prospective observational study model where baseline audit data was compared with data observed after the implementation of quality improvement strategies. The data was collected through an audit of the medical records of all pediatric patients receiving oxygen therapy in the PICU. Knowledge and perception of healthcare workers about oxygen therapy were assessed via a self-designed questionnaire. The study was undertaken in three phases, including Quality Improvement (QI) team formation and data collection, root cause analysis, and implementation of Plan-Do-Study-Act (PDSA) cycles. Observations and results In the baseline audit, 1.4% of the prescriptions were complete and valid. Subsequently, over the course of four PDSA cycles, valid prescription rates increased; 62.07% in the first, 79.51% in the second, 81.81% in the third, and 91.42% in the fourth cycle respectively. After applying the chi-square test to compare PDSA4 and baseline data, the p-values for written prescriptions and target saturation were found to be statistically significant. In the healthcare worker survey, we found that 100% of them were aware of indications of oxygen prescription, FiO2, and side effects of excessive usage of oxygen therapy, 95% were aware of conditions affecting pulse-oximetry in the pediatric age group, and 75% knew about target saturation and its significance and the procedure to change alarm settings on the monitor. Conclusion Currently, there exists a lack of effective oxygen prescription audits, especially in India, which can be attributed to a lack of awareness and partly, a lack of initiative. Quality improvement initiatives are effective in improving the valid oxygen prescription rate. However, sustained goals can be achieved through regular audits only.

Genetic Expression of CYP2B6 Gene in Phenobarbitone Responder and Non- responder Neonates

Quantitative real-time polymerase chain reaction for identifying CYP2B6 gene expression was done on blood samples of 30 phenobarbitone responder and 30 non-responder neonates with seizures. CYP2B6 was observed to be significantly down regulated among phenobarbitone non-responders as compared to phenobarbitone responders (Mean (SD) DCt 17.97 (1.19) vs 15.40 (1.83); P<0.001).

Re-visiting micro ESR as a screening tool for neonatal sepsis

Our study evaluated the role of micro-erythrocte sedimentation rate (micro-ESR) in the early detection of neonatal sepsis.

Neonates with >34 completed weeks of gestation, appropriate for gestational age, admitted in our Neonatal Intensive Care Unit with clinical suspicion of early onset sepsis were enrolled in the study. A sepsis screen and blood culture was performed on all the babies within 4 h of admission. The sensitivity of micro-ESR for detecting positive blood culture was calculated and the best cut-off was determined using the Area Under Curve.

Changing epidemiology of poisoning in children: A retrospective study from a tertiary care center in New Delhi, India

Poisoning is the fourth leading cause of unintentional injuries in children. With continuously changing environment, the epidemiology of poisoning keeps on changing. The present study was undertaken to describe the clinical and epidemiological profile of childhood poisoning in a tertiary care center of New Delhi, India. All children <12 years of age admitted to pediatric ward with a history of ingestion of poison or envenomation between January 2019 and June 2020 were identified, and their medical records were obtained from medical records department. A total of 203 patients were enrolled in the study. Drugs and medications were the most common agents (19.2% cases), followed by prallethrin (13.7% cases). Majority of the cases were asymptomatic. Vomiting (25%) was the most common symptom. Drugs and medications were the leading cause of poisoning, followed by liquid mosquito repellant. This study highlights the change in characteristics of acute poisoning in Indian children.

Saving oxygen when it was most needed

Background

Oxygen is one of the most commonly prescribed drugs across the globe. The ongoing Covid-19 pandemic has put enormous burden on hospital infrastructure and oxygen demand. There is lack of knowledge among healthcare workers regarding optimal utilization of oxygen delivery devices, target oxygen saturations and adequate oxygen prescription. A quality improvement project was designed to optimize the oxygen usage in wards.

Methods

A core team comprising one each of consultant, senior resident, junior resident and nursing officer was formed. Fish bone analysis was done to find deficiencies in the existing system and strategy was planned to overcome these deficiencies. The key intervention included education and training of staff, Formulation of Standard Operating Procedures, use of lower target oxygen saturation and use of oxygen concentrators.

Results

The project was carried out for a very short period of 5 days, and a total of 180,000 liters of oxygen was saved. The use of oxygen concentrators increased from zero to 9.5% and thus reducing the load on central oxygen supply.

Conclusion

The proper training and sensitization of health care workers can help in saving oxygen, which further helps in saving precious human life.

Impact of maternal iron deficiency anaemia on the expression of the newly discovered multi-copper ferroxidase, Zyklopen, in term placentas

In the present study, we investigated the effect of maternal iron deficiency anaemia (IDA) on expression of the newly discovered iron transporter, Zyklopen in term placenta, in 200 pregnant women. Placental expression of Zyklopen was studied by mRNA analysis and immunohistochemistry for the protein. In addition neonatal anthropometric parameters were also analysed. 58.8% of 200 subjects were anaemic. Both Zyklopen mRNA as well as protein expression in the placenta showed a statistically significant increase with increasing severity of anaemia. Although all the neonatal anthropometric parameters were lower in newborns of anaemic mothers, none showed any statistical significance. Zp mRNA levels did not show any significant correlation with newborn and placental parameters (except newborn skinfold thickness and head circumference). Similar to mRNA expression, Zp IHC expression correlated positively, albiet non-significantly, with newborn length and Hb levels, the correlation was however negative with birth weight, head circumference, mid-arm circumference unlike the mRNA expression, where it positively correlated with the above parameters. Our study for the first time demonstrated a definite increase in expression of Zyklopen at both mRNA and protein levels in term placenta, in maternal IDA.IMPACT STATEMENTWhat is already known on this subject? Iron deficiency anaemia (IDA) in a pregnant mother can lead to anaemia in the developing foetus; which is frequently observed to be of lesser severity than that in the mother. Recently a copper-containing oxidase called Zyklopen was discovered which was involved in iron efflux in BeWo cells. The gene encoding Zyklopen has been identified with a putative C-terminal membrane-spanning sequence and high sequence identitical to hephaestin (Heph) and ceruloplasmin (Cp), the other known vertebrate multicopper ferroxidase (MCF). Protein expression of this new MCF was observed in multiple diverse mouse tissues, including placenta and mammary gland.What do the results of this study add? Zyklopen protein immunohistochemical expression showed a statistically significant increase with increasing severity of anaemia. Similarly, placental mRNA expression of the Zyklopen gene was observed to be higher in anaemic mothers when compared to non-anaemic mothers. Our study for the first time demonstrated a definite increase in expression of Zyklopen at both protein and mRNA levels in term placenta, in maternal IDA.What are the implications of these findings for clinical practice and/or further research? This study will help us to understand better, the increased potential for influx of iron from mother to foetus in the condition of maternal iron deficiency. This study will help to determine how placental iron transport proteins can be regulated in response to maternal and neonatal iron status and will further our existing knowledge on relationships between maternal and neonatal iron status and mechanisms by which placental iron transport is modified in relation to these parameters.

Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports

Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.

Identifying Serious Bacterial Infections in Febrile Young Infants

Fever is one of the most common presenting complaints among infants brought to pediatric emergency. Although most of the infants have benign, self-limiting viral infections, approximately 10% of all may have serious bacterial infection. Clinical examination alone is insufficient to detect serious bacterial infection in well appearing infants, and a standardized approach is always sought for. However, guidelines used in the United States or European countries may not be applicable in a tropical country like India. Deviation from these guidelines leads to challenges of unwarranted hospitalization and antibiotic usage, extra cost of care and risk of antimicrobial resistance. Various prediction rules can detect a low risk infant with negative predictive values ranging from 93.7-100%. While use of biomarkers such as C reactive protein and procalcitonin can be reliable, it is costly and may not be applicable to the local population. Validation studies over varied population are needed in future.

143 Therapeutic efficacy and safety of adipose tissue-derived mesenchymal stem cells in treating mastitis and metritis in dairy cattle

Mastitis and metritis are two inflammatory diseases with high economic impact on dairy industry and farmers are losing revenues. Antibiotic treatment for these disease conditions typically achieve suboptimal outcomes. Moreover, emerging antibiotic resistance in mastitis and metritis worldwide has a severe effect on productivity, fertility, and lifespan of animals. A paradigm shift in treatment strategies is much needed for these animals. Attracting properties of mesenchymal stem cells may act as an alternative strategy for treating these diseases. In addition to their ability to differentiate into multiple types of cells, mesenchymal stem cells can orchestrate immune responses and modulate tissue microenvironments. In the present study, we evaluated the safety and efficacy of adipose tissue–derived mesenchymal stem cells (AT-MSC) for mastitis and metritis. A well-characterised adipose-derived stem cell line with 3–5 passages cells were used for treatment for these diseases. In a safety trial, mastitis- and metritis-infected cattle were administered with 1×106 cells of AT-MSC through different routes (local, IV, IV+local). Animals were clinically evaluated during 15 days of the experimental period and blood samples were collected for hemogram determination. The efficacy was checked under both invivo and invitro conditions. Invitro efficiency of AT-MSC was determined using a transwell plate experiment, in which AT-MSC were co-cultured with bacteria (Escherichia coli and Staphylococcus). Invivo efficiency was evaluated by administration of in 2mL (1×106 cells) of AT-MSC dose; then, somatic cell count (SCC) in milk of mastitic cattle and polymorphonuclear (PMN) cell count in cervical vaginal fluid (CVF) of metritic cattle were determined. Gene expression profiling of antimicrobial (cathelicidin, lipocalin, cystatin) and anti-inflammatory (IL-4, IL-6, IL-10) peptides were quantified in all groups: IV, local, IV+local, and control ATB (antibiotic). Allogenic AT-MSC did not induce any immunological rejection response in treated animals. A significant reduction of bacteria in CVF invitro when co-cultured with AT-MSC was observed. The PMN count was significantly reduced in CVF of the IV+local group. The SCC in milk of mastitic animals was decreased in the local (intramammary) group. Maximum expression of IL-6, IL-10, cathelicidin, lipocalin, and cystatin and angiopoietin genes were observed on Day 3 followed by Day 7 in the local group in case of mastitis. In metritis, expression of IL-6, IL-10, cathelicidin, lipocalin, cystatin, and angiopoietin were observed at Day 3 in the IV+local group. All mastitic and metritic cattle were completely and permanently cured within 30 days after treatment with mesenchymal stem cells. In conclusion, we provide initial evidence for the use of allogenic AT-MSC and their safety and efficacy to treat mastitis and metritis in dairy cattle.

Recurrent arthritis: an unusual diagnosis

Musculoskeletal complaints may be the initial manifestation of childhood leukaemias. When these symptoms predominate at the onset, a diagnosis of one of several rheumatic diseases may be entertained. Where blood tests are normal, no bone marrow examination would normally be indicated. The use of immune-suppressing medication, such as steroids, may lead to diagnostic delay or misdiagnosis.

Expression of iron transport protein Divalent metal transporter 1 (DMT1) increases in response to maternal iron deficiency anemia in near term to term placenta

Introduction: Iron deficiency anemia (IDA) is the most prevalent nutritional deficiency disorder in pregnant women. During pregnancy, placental transport protein Divalent metal transporter1 (DMT1) plays a crucial role in transit of iron across placenta. The developing fetus is observed to be immune to anemia despite presence of anemia in the mother. Hence, we planned the present study to explore the effect of maternal IDA on the expression of DMT1 in the placenta.Materials and methods: Two hundred pregnant women recruited, were divided into anemic and nonanemic groups based on their predelivery hemoglobin levels (<11 g/dL and ≥11 g/dL respectively). After delivery, placental expression of DMT1 was studied by immunohistochemistry and mRNA analysis and neonatal anthropometry was performed.Results: Of the 200 women recruited, 58.8% were anemic with 60.35% having moderate anemia. Most of the red cell parameters were observed to be higher in cord blood than mothers. DMT1 protein immunohistochemical expression showed a statistically significant increase with increasing severity of anemia. Similarly, placental mRNA expression levels of DMT1 gene were observed to be higher in anemic mothers in comparison with nonanemic mothers.Conclusion: Our study thus demonstrated a definite increase in expression of DMT1 at both protein and mRNA levels in term placenta, in maternal IDA.

Protective Effect of Turmeric against Bisphenol-A Induced Genotoxicity in Rats

In this study, the protective role of turmeric on genotoxic effects of Bisphenol-A exposure in Wistar rats by in vivo experiment were investigated. Bisphenol-A is a known endocrine disruptor and suspected carcinogen, that comes diet through plastics for food packaging and food processing. In this study, rats were divided into three groups of twelve animals each and were administered with Bisphenol-A by oral gavage with levels of 0, 50 and, 100 μg. Half of the animals in each group were fed with feed which contained 3% turmeric (wt/wt), for a period of 4 wk, while the rest of the rats received the same diet treatment without the addition of turmeric. At the end of the experiment, all rats were terminated and the internal organs such as liver, kidney, femurs were collected and analyzed. Mean and SD values were compared by one-way ANOVA and Kruskal-Wallis-Wilcoxon test, the formation of micronuclei was compared using Mann-Whitney U-test. Significant decrease in serum malondialdehyde and urinary 8-hydroxy-2'-deoxyguanosine levels were observed in Bisphenol-A+turmeric groups as compared to Bisphenol-A groups. Bisphenol-A groups exhibited significantly higher mean levels of DNA damage in liver and kidney as compared to the untreated control group. Bisphenol-A group showed significant increase in the formation of micronuclei which was approximately threefold higher as compared to the control group. A significant decrease in DNA migration was observed in Bisphenol-A+turmeric fed groups in liver and kidney. Turmeric feeding significantly inhibited the micronuclei formation induced by Bisphenol-A. The study results indicate that turmeric can protect against Bisphenol-A induced genotoxicity in rats.

Prolonged consumption of grass pea (64 g/Cu/day) along with millets and other cereals causes no neurolathyrism

Objective: To assess the safe limit of L. sativus (grass pea) consumption along with cereals and millets.Methods: A community-based cross-sectional study was undertaken in three districts (Bilaspur, Durg and Raipur) of Chhattisgarh state. A total of 1500 households (HHs) were surveyed. A total of 360 split grass pea (SGP) samples were collected from all three districts for ?-ODAP analysis. Clinical examination was carried out for symptoms of neurolathyrism. Diet survey was done on 5769 HHs by 24hr recall method. Mean intake of different foods and nutrients were calculated. Based on food frequency questionnaire, HHs were separated into daily consumers of SGP along with its quantity consumed and that never consumed SGP.Results: The study revealed that 30 daily consuming and 89 never consuming HHs, in all the three districts. Daily SGP was consumed at an average of 64 g/Cu/day along with millets, cereals and vegetables. Whereas among the never consumers of SGP, mean intake of vegetables was higher than recommended intakes in addition to pulses. The average ?-ODAP content in SGP was 0.630 g%. The nutritional status of children <5 years and the adults was not significantly different between the daily SGP consumers and never consumers. Households in all the three districts, who consumed the SGP recipes, followed the method of washing, boiling, draining the excess water and cooking the pulse.Discussion: There were no adverse effects observed among daily consumers of grass pea (64 g/CU/day) along with millets, cereals and vegetables.

Effect of probiotic supplementation on total lactobacilli, bifidobacteria and short chain fatty acids in 2-5-year-old children

​Background: Consumption of Lactobacillus paracasei Lpc-37 or Bifidobacterium lactis HN019 by 2-5-year-old children was found to reduce risk for diarrhoea and fever during the rainy season. Objective: Can changes in faecal short chain fatty acids (SCFAs) or branched chain fatty acids (BCFAs) explain the observed positive influence of probiotics and their role on nutritional status and diarrhoea risk? Design: Faecal samples were analysed for SCFAs and BCFAs and correlated to Bifidobacterium and Lactobacillus levels; both at the start and after nine months' consumption of either of the two probiotic strains, or placebo. Results: No differences in SCFAs, BCFAs, Lactobacillus or Bifidobacterium levels were found between boys and girls. Severely underweight children were observed to have the highest Lactobacillus levels. Probiotic intervention was found to be associated with higher levels of selected SCFAs and BCFAs in subjects who had experienced diarrhoea. Treatment with either of the probiotics led to changes in SCFAs and BCFAs. SCFAs, acetate, propionate and butyrate, were found to correlate with each other. Likewise, BCFAs isobutyrate, 2-methylbutyrate and isovalerate correlated with each other. After the intervention, L. paracasei Lpc-37 correlated positively with total Bifidobacterium counts and isovalerate levels. B. lactis HN019 counts were found to correlate positively with total bacterial counts and negatively with propionate levels. Conclusions: ​Nutritional status was associated with higher levels of faecal lactobacilli; the meaning of this requires further investigation. The intervention with the two probiotics was observed to influence the levels of faecal SCFAs and BCFAs and there is a differential response in those who developed diarrhoea and those who did not. It is, however, not clear to what extent this is a mechanism that explains the earlier observed effect the strains had on diarrhoea risk.

Diet & nutrition profile of Chenchu population - A vulnerable tribe in Telangana & Andhra Pradesh, India

Background & objectives:

Earlier studies have documented high prevalence of undernutrition, morbidity and mortality among Chenchus, a tribal population in Telangana and Andhra Pradesh, India. The present study was carried out to assess diet and nutritional status of Chenchus and cause of death.

Methods:

A total of 42 Chenchu villages (gudems) were covered using systematic random sampling procedure. In each gudem, all the households with at least one child under the age of five years were covered for various investigations. Weighment diet survey was carried out on a sub-sample of households. In addition, information on cause of death in the selected 42 gudems was collected for past one year using verbal autopsy method.

Results:

A total of 1396 subjects of all age groups were covered for various investigations. The intakes of food and nutrients were lower than the recommended levels. The prevalences of underweight, stunting and wasting among under five children were 42 per cent (CI: 37.9-46.1), 53 and 13 per cent, respectively, while 41 per cent (CI: 37.8-47.2) men and 42 per cent (34.4-47.8) women had chronic energy deficiency (BMI<18.5 kg/m²). Sixty eight deaths were reported during the past one year in 42 Chenchu gudems. The major causes of death were premature delivery, low birth weight, alcoholic cirrhosis of liver, accidents, snakebite and pulmonary tuberculosis.

Interpretation & conclusions:

The prevalence of undernutrition in Chenchu population was comparable with other tribal and rural counterparts in Andhra Pradesh, however, the crude death rate (11.7/1000) was higher among the Chenchus. Steps may be taken to promote consumption of balanced diet and utilization of optimal healthcare facilities to control morbidity and mortality.

Health & nutritional status of HIV infected children in Hyderabad, India

BACKGROUND & OBJECTIVES

Information on nutritional status of HIV infected children from India is lacking and is required before taking up nutritional supplementation trials. Thus, the aim of the present study was to assess the growth and morbidity status of HIV infected children over a period of one year in a city in southern India.

METHODS

This was an observational study carried out between July 2009 and February 2011, at two orphanages in Hyderabad, India. Seventy seven HIV-positive children aged between 1 and half and 15 years, both on and not on antiretroviral therapy (ART) were included. Nutritional status was assessed longitudinally for one year by weight gain, linear growth and body composition. Serum samples were analyzed for haemoglobin, micronutrients, CD4 and CD8 counts. Dietary intakes were assessed by institutional diet survey and morbidity data were recorded every day for 12 months.

RESULTS

Mean energy intakes were less than recommended dietary allowance (RDA) in all age groups. Iron and folate intakes were less than 50 per cent of RDA; 46 (59.7%) children were stunted, 36 (46.8%) were underweight and 15 (19.5%) had low BMI for age. Anaemia was observed in 35 (45.5%) children. Micronutrient deficiencies such as vitamin D (40/77; 51.9%), vitamin A (11/77; 14.3%), folate (37/77; 48.1%), iron (38/77; 49.3%) were widely prevalent. HIV viral load was higher in children not on ART and those with morbidity. Respiratory (36.6%) and dermatological illnesses (18.8%) were the commonest presentations.

INTERPRETATION & CONCLUSIONS

Acute, chronic malnutrition and micronutrient deficiencies were common in HIV infected children, especially in those not on ART and having morbidity. With severe malnutrition being an alarming consequence of HIV, prophylactic nutritive care should be considered for integration into HIV care strategies besides initiation of ART to improve the nutritional status and quality of life of these children.

Microbiological Quality of Salads Served along with Street Foods of Hyderabad, India

A study has been done to analyse the microbiological quality of salads served along with street foods of Hyderabad. A total of 163 salad samples, 53 of carrot and 110 of onion samples, were collected from four different zones of Hyderabad. About 74% and 56% had Staphylococcus aureus in carrots and onions, respectively. Fifty-eight percent of carrots and forty-five percent of onions samples contained Salmonella, 68% of carrots and 24% of onions had Yersinia. HACCP study was carried out with 6 street food vendors to identify the source of Salmonella contamination in salads. Food handlers were found to be responsible for Salmonella contamination in salads. The present study revealed the potential hazards of street vended salad vegetables, considering the handling practice usually carried out by vendors. Ninety-eight percent of the vendors did not wash the vegetables before processing and serving while about 56.6% of the vendors did not peel the vegetables. Majority of street vendors' nails were uncut. A significant difference (P < 0.01) was observed in Yersinia spp. and Salmonella spp. in wet-dirty chopping board when compared to clean-dry chopping board. A significant difference (P < 0.05) of Staphylococcus spp. was observed when the status of cleaning cloth was neat/untidy.

Speedy orthodontics: a case report

Management of severe rotation poses a great challenge for the orthodontist, especially when cortical anchorage occurs. The conventional methods require excessive treatment time, rely on patient compliance, and can cause root resorption. A groundbreaking new procedure developed by Wilcko et al, which is actually a modification of the conventional corticotomy procedure, amalgamates the orthodontic mechanics, alveolar decortications, and augmentation procedure to make treatment time three to four times faster than conventional orthodontic techniques. This procedure uses the dynamics of bone physiology and redirects the emphasis in tooth movement to the manner in which supporting bone responds to orthodontic forces applied to the tooth. This article includes a case report in which the technique is used on a patient who has a severely rotated mandibular left canine.

XMetA, an allosteric monoclonal antibody to the insulin receptor, improves glycaemic control in mice with diet-induced obesity

XMetA, a high-affinity, fully human monoclonal antibody, allosterically binds to and activates the insulin receptor (INSR). Previously, we found that XMetA normalized fasting glucose and glucose tolerance in insulinopenic mice. To determine whether XMetA is also beneficial for reducing hyperglycaemia due to the insulin resistance of obesity, we have now evaluated XMetA in hyperinsulinemic mice with diet-induced obesity. XMetA treatment of these mice normalized fasting glucose for 4 weeks without contributing to weight gain. XMetA also corrected glucose tolerance and improved non-high density lipoprotein cholesterol. These studies indicate, therefore, that monoclonal antibodies that allosterically activate the INSR, such as XMetA, have the potential to be novel agents for the treatment of hyperglycaemia in conditions associated with the insulin resistance of obesity.

Prevalence and characteristics of Molar Incisor Hypomineralisation (MIH) in the child population residing in Gandhinagar, Gujarat, India

Most prevalence studies on Molar Incisor Hypomineralisation (MIH) have been carried out in European countries and data from Asia especially south Asian populations are lacking.

AIM

To investigate the prevalence and clinical characteristics of MIH in children residing in a western region of India.

METHOD

A cross-sectional survey including 1,366 children from 5 age cohorts, 8-12 years, studying in primary schools or attending the University Department, was carried out in the area of Gandhinagar, Gujarat, India. The dental examination was performed by a single well-trained and calibrated examiner in day light conditions. Full mouth inspection of wet teeth was conducted using the EAPD 2003 criteria for diagnosis of MIH. Results were recorded and statistically analysed using Chi-square test, independent sample t-test and Pearson correlations.

RESULTS

Prevalence of MIH was 9.2% in the examined population. Males and females were equally affected. Among 12 index teeth involved in the examination, the most commonly affected were in descending order 46, 36, 16, 11 [FDI] and the least 42, 32, and 22. 17.4% of the cases revealed only molars involved, the remaining 72.6% having both molars and incisors affected; all four first permanent molars showed in 23% of the cases while no cases of only affected incisors were found. Of the MIH teeth 77.3% revealed mild defects and 22.7% severe defects. All incisors were mildly affected, as compared with only 67.1% of the molars, the remaining 32.9% being severely affected. As age increased, a statistically significant larger total number and severity level of affected teeth were recorded.

CONCLUSION

Prevalence of MIH using EAPD 2003 criteria was found to be similar to other studies evaluating children in different geographic locations such as Europe, South America etc. Using the EAPD standardised criteria, more studies should be conducted in other Indian regions, in order to further evaluate prevalence, characteristics and treatment needs for this clinically demanding condition.

Impact of a behaviour change intervention model for promotion of condoms amongst young adult males in an occupational setting

BACKGROUND

Studies have justified that social and cultural factors influence young people not to use condoms. Sexually active people associate condoms with lack of trust, while others believe carrying them could imply sexual inexperience. The aim of this study was to provide an intervention model based on this social perception and assess the impact of the intervention in improving condom use.

METHODS

2083 personnel in the intervention group were subjected to behaviour change intervention based on perception and use of condoms. Using a cluster design, we randomly assigned 40 departments to department-based intervention (20) or assessment (20) groups. Around 100 persons in the same age group of 18-45 years were again randomly assigned to each group. Chi Square test was used to assess the effectiveness of the intervention.

RESULTS

Over 6% individuals in the control group (Table 2) had non-regular partners and out of them 23.5% had used a condom. Again, in the same group (Fig. 1), 45.36% individuals thought it is acceptable for single men to use condoms with their partners and 8.15% agreed that it is alright for married women to use condoms with their husbands. The perception significantly increased in the intervention group (p < 0.001).

CONCLUSION

This study thus highlights the importance of continued behavioural intervention in filling certain gaps in the social and structural perception to improve condom use for effective HIV prevention in the community.

Microbiological hazard identification and exposure assessment of poultry products sold in various localities of Hyderabad, India

A study was carried out to identify microbiological hazards and assess their exposure associated with consumption of poultry based street food served in different localities of Hyderabad. The study indicated that chicken 65, chicken fried rice, chicken noodles, chicken Manchuria and chilly chicken are the most common recipes. A process flow diagram was developed to identify critical control points in the food item. After analysis of the samples at each level of preparation, it was observed that rice and noodles were kept at room temperature for about 5-6 hrs which was a critical control point. A total of 376 samples including chicken fried rice, chicken noodles, boiled noodles and boiled rice were collected from circle 1, 2, 3, 4, 5, 6, and 7 of Greater Hyderabad municipal corporation (GHMC) and analyzed for microbiological examination. The most prevalent pathogenic bacteria isolated were S. aureus (3.4 log 10 cfu/g) and B. cereus (3.4 log 10 cfu/g). Salmonella spp. was present in salads (3.2 log 10 cfu/g) and hand washings of the food handler (3.5 log 10 cfu/g). Salmonella contamination was found in salads served along with chicken fried rice and chicken noodles than in the food.

The effectiveness of a musical toothbrush for dental plaque removal: a comparative study

BACKGROUND AND OBJECTIVES

the purpose of this study was to clinically evaluate and compare the efficacy of "Brush Buddies" musical tooth brush and Colgate Smile tooth brush in the reduction of established plaque and gingivitis.

MATERIALS AND METHODS

for this study, 120 healthy kids (73 boys and 47 Girls) were selected. The subjects were randomly assigned into two groups by a second examiner; one group used Colgate Smile brush and the other group used "Brush Buddies" musical tooth brush. Plaque index (Quigley and Hein), Modified Gingival Index (Lobene and Associates) and Gingival Bleeding Index (Ainamo and Bay) were assessed at baseline, 30th day, 60th day, and 90th day.

RESULTS

all the baseline indices appeared to be well balanced. At the end of the study, reduction in plaque index, modified gingival index and gingival bleeding index were statistically highly significant during each interval for both the toothbrushes. For "Brush Buddies" musical tooth brush, the reduction in all clinical parameters were statistically significant for 30 days and 60 days interval, while nonsignificant at 90 days interval.

INTERPRETATION AND CONCLUSION

both the tooth brushes used in this study were clinically effective in removing plaque, improving gingival health. Musical tooth brush is more effective initially but as the time period increases both tooth brushes give almost similar results.

Biodegradation of nickel and chromium from space maintainers: an in vitro study

Band materials are often used in the practice of pediatric dentistry. Nickel and Chromium are the main ingredients of these materials. The potential health hazards of nickel and chromium and their compounds have been the focus of attention for more than 100 years. It has established that these metals could cause hypersensitivity. The study was undertaken to analyze in vitro biodegradation of space maintainers made out of stainless steel band materials from manufacturers Dentaurum and Unitek. The leaching effect simulating the use of one, two, three, and four space maintainers in clinical practice was studied by keeping the respective number of space maintainers in the artificial saliva incubating at 37 degrees C and analyzing for nickel and chromium release after 1,7,14,21 and 28 days using atomic absorption spectrophotometer. Results showed that there was measurable release of both nickel and chromium which reached maximum level at the end of 7 days which was statistically significant (P < 0.05) and was very much below the dietary average intake even for four bands used and was not capable of causing any toxicity.

Sinus histiocytosis with nodal and extranodal involvement--a case report

A two and half years old male child of sinus histiocytosis with massive lymphadenopathy, paraplegia and spinal cord involvement was treated with surgery and radiotherapy for the spinal cord compression and later with chemotherapy for his nodal disease in the neck. There was a significant improvement in his neurologic status as well as in his nodal status reiterating the role of combination therapy in this disease.

Postoperative Mycobacterium chelonae endophthalmitis after extracapsular cataract extraction and posterior chamber intraocular lens implantation

OBJECTIVE

To describe a case of postoperative endophthalmitis caused by Mycobacterium chelonae after extracapsular cataract extraction with posterior chamber intraocular lens implantation.

DESIGN

Interventional case report.

METHODS

The history and clinical presentation of a 66-year-old female patient, in whom a low-grade delayed-onset endophthalmitis and keratitis developed after extracapsular cataract extraction with posterior chamber intraocular lens implantation, is described. Microbiologic investigations of the scrapings of corneal infiltrate at the cataract incision site, aqueous humor and eviscerated material, and histopathologic study of eviscerated material and an enlarged cervical lymph node were performed.

MAIN OUTCOME MEASURES

The clinical, histopathologic, and microbiologic findings in a case of low-grade delayed-onset endophthalmitis.

RESULTS

Analysis of the direct smear of both the corneal infiltrate as well as the eviscerated material revealed acid-fast bacilli. M. chelonae was isolated from these specimens. Direct smear and culture of the aqueous humor were negative for bacteria (including mycobacteria) and fungus. Histopathologic examination of the eviscerated material showed a dense infiltration of polymorphonuclear leukocytes in the uveal tissue, extensive necrosis and hemorrhage, and exudates with hemorrhage in the vitreous cavity. Histopathologic examination of the lymph node revealed granulomatous inflammation with caseation necrosis, but did not reveal acid-fast bacilli.

CONCLUSIONS

M. chelonae, although infrequent, should be considered an etiologic agent of delayed-onset, postoperative endophthalmitis and early bacterial diagnosis should help in institution of appropriate therapy.

A functional interaction between dorsal and components of the Smt3 conjugation machinery

To identify proteins that regulate the function of Dorsal, a Drosophila Rel family transcription factor, we employed a yeast two-hybrid screen to search for genes encoding Dorsal-interacting proteins. Six genes were identified, including two that encode previously known Dorsal-interacting proteins (Twist and Cactus), three that encode novel proteins, and one that encodes Drosophila Ubc9 (DmUbc9), a protein thought to conjugate the ubiquitin-like polypeptide Smt3 to protein substrates. We have found that DmUbc9 binds and conjugates Drosophila Smt3 (DmSmt3) to Dorsal. In cultured cells, DmUbc9 was found to relieve inhibition of Dorsal nuclear uptake by Cactus, allowing Dorsal to enter the nucleus and activate transcription. The effect of DmUbc9 on Dorsal activity was potentiated by the overexpression of DmSmt3. We have also identified a DmSmt3-activating enzyme, DmSAE1/DmSAE2 and found that it further potentiates Dorsal-mediated activation.

Pulmonary infections after kidney transplantation

OBJECTIVE

To retrospectively analyse the epidemiology, aetiology, temporal profile and outcome of lung infection following kidney transplantation.

METHODS

Out of 142 consecutive renal transplant (RT) recipients who underwent live donor transplantation from June, 1990 to May, 1998, 43 (33%) had serious infection requiring hospitalisation of which 27 were pulmonary. All such pneumonia were included for retrospective analysis. All had a minimum follow up of six months (if alive) and were on triple drug immunosuppression. All had detailed and appropriate investigations for definitive diagnosis.

RESULTS

The aetiological agents were Gram negative bacterial infection (2), Gram positive bacterial infection (1), nocardia (2), tuberculosis (10), aspergillosis (2), mixed bacterial and fungal infection (4), Pneumocystis (2) and unconfirmed (4). Four patients had pneumonia because of probable nosocomial exposure. Radiologically lobar/segmental pneumonia was observed in five, nodular lesion six, reticulonodular lesion eight, patchy consolidation five and pleural effusion three. Nodular pneumonias were due to aspergillosis or nocardiosis. Four patients developed secondary cavitation. Pulmonary infections were significantly associated with leucopenia (8/27) (p < 0.01) but not with renal dysfunction (creat > 2 mg%), diabetes, old age or additional immunosuppression (p > 0.05). There were 11 deaths. Mortality was related to failure to reach diagnosis (3) and delayed institution of therapy (6 patients). Pneumonia within first six months had a higher mortality (9/16) compared to late pneumonia (2/11). Immunomodulating virus (CMV 4, HEP B 2) was present in six patients of whom four succumbed.

CONCLUSION

Pulmonary infection is a common and serious post-transplant infection requiring hospitalisation, is associated with high mortality. Patients with leucopenia are predisposed to these infections. Prophylaxis for Pneumocystis, Nocardia and tuberculosis needs strong consideration to reduce mortality of such infection. Nosocomial exposure risk needs careful consideration in outbreaks of opportunistic infection.

Evidence for two distinct G-protein-coupled ADP receptors mediating platelet activation

The identity of the receptors mediating platelet activation by ADP remains elusive. To distinguish between platelet ADP receptor subtypes, the effects of antagonists on platelet responses and the cloned P2Y1 receptor, a putative platelet ADP receptor, have been investigated. 2-methylthio-AMP (2MeSAMP), an inhibitor of ADP-dependent platelet aggregation, antagonized ADP-mediated inhibition of adenylyl cyclase, competed with binding of [3H]2-methylthio-ADP and inhibited the stimulation of [35S]GTPgammaS binding. 2MeSAMP did not inhibit platelet shape change and was only a weak antagonist of intracellular calcium mobilization in platelets or in cells expressing the cloned human P2YI receptor. By contrast, the P2Y1 receptor antagonist adenosine 3',5'-diphosphate (A3P5P) inhibited ADP-induced platelet aggregation, completely abolished shape change, but did not antagonize ADP effects on cyclic AMP generation or [3H]2-methylthio-ADP binding. However, A3P5P antagonized intracellular calcium mobilization in platelets and cells expressing the cloned P2Y1 receptor. Furthermore, using a specific monoclonal antibody and flow cytometry, P2Y1 receptor protein was detected on human platelets. These results support the existence of two G protein-coupled ADP receptors mediating platelet aggregation, one of which is coupled to Gi proteins and blocked by 2MeSAMP, whereas the second receptor is similar or identical to P2Y1 and coupled to Gq.

Lung volume reduction surgery. Case selection, operative technique, and clinical results

OBJECTIVE

A clinical study was undertaken to define optimal preoperative strategies and intraoperative techniques that would result in the least morbidity and maximum physiologic improvements in patients with end-stage emphysema selected for lung volume reduction surgery.

BACKGROUND

Lung volume reduction surgery recently has been advocated as an alternative or a bridge to lung transplantation for patients with end-stage chronic obstructive pulmonary disease. The risks, benefits, and long-term results have not been clarified.

METHODS

Twenty-six patients underwent lung volume reduction surgery with a 3-month follow-up on 17 patients. Preoperative and postoperative changes in pulmonary function parameters, quality of life, and oxygen requirement were analyzed. The value of preoperative localization of diseased lung segments and how this affects intraoperative resection is addressed.

RESULTS

Forty-nine percent improvement in FEV1 (forced expiratory volume in 1 second) and 23% improvement in FVC (forced vital capacity) were seen after lung volume reduction surgery. Supplemental oxygen requirement was decreased and 79% of patients reported a much better quality of life. Mortality was 3.8% and air leak morbidity was 18%.

CONCLUSIONS

Lung volume reduction surgery can predictably improve objective and subjective pulmonary function in selected patients with end-stage emphysema with low morbidity and mortality. Careful patient selection, accurate preoperative localization of diseased target areas, skilled anesthetic technique, meticulous operative approach, and intense postoperative support are essential to achieve favorable results.