An open label non-inferiority randomized controlled trial evaluated alternate day prednisolone given daily during infections vs. levamisole in frequently relapsing nephrotic syndrome

Initial therapies for children with frequently relapsing nephrotic syndrome include alternate-day prednisolone that is given daily during infections, or levamisole. In this open label, non-inferiority trial, 160 patients, 2 to 18-years-old with frequent relapses, were randomly assigned to receive either prednisolone (0.5-0.7 mg/kg/alternate-day, given daily during infections), or levamisole (2-2.5 mg/kg/alternate-days) for one-year. Patients with relapses on alternate day prednisolone at over 1 mg/kg, prior use of potent steroid-sparing therapies, eGFR under 60 ml/min/1.73 m2 and significant steroid toxicity were excluded. Primary outcome was the proportion of patients with frequent relapses, defined as three-relapses in one-year, or two-relapses within six-months if associated with significant steroid toxicity or loss to follow up. Eighty patients each were randomized to receive prednisolone and levamisole. Baseline features showed preponderance of young patients presenting within two-years of disease onset. On intention-to-treat analysis, frequent relapses were more common in patients administered prednisolone (40% versus 22.5%; risk difference 17.5%; 95% confidence interval 3.4-31.6%). Prednisolone was not non-inferior to levamisole in preventing frequent relapses. However, the two groups showed similar proportions of patients in sustained remission, comparable frequency of relapses, and low frequency of adverse events. The decline in steroid requirement from baseline was higher in the levamisole group. Per-protocol analysis showed similar results. These results have implications for choice of therapy for frequently relapsing nephrotic syndrome. Although therapy with alternate-day prednisolone was not non-inferior to levamisole in preventing frequent relapses, both therapies were effective in other outcome measures. Thus, levamisole was relatively steroid-sparing and may be preferred in patients at risk of steroid toxicity.

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI"

BACKGROUND

Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind.

METHODS

The ASPIRE study (part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18 years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice.

RESULTS

From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17 years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%.

CONCLUSIONS

Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

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.

Comparative Evaluation of Various Lens and Ring Flash Combination for Intraoral Photography

BACKGROUND

Extraoral and intraoral dental photographs serve as preoperative records and document the entire treatment. Correctly composed orthodontic photographs are crucial for remote diagnosis and may serve as a bulwark against medicolegal challenges.

MATERIALS AND METHODS

In this prospective study, intraoral frontal photographs of patients with ideal occlusion were taken using two types of lenses (EF-S 18-55 mm f/3.5-5.6 IS STM lens (Canon, Tokyo, JP), SP 90 mm F/2.8 MACRO VC lens (Model F017 Tamron, NY, USA)) and two different ring flash systems (Meike FC-100 Macro Ring LED Light (Meike, China), Macro Ring flash Lite YN-14EX (Yongnuo digital, China)). The combination of lens and flash used was grouped into four groups. Twenty-eight intraoral photographs of patients were taken. An image quality assessment survey was distributed among two groups - 50 orthodontists and 50 other dental specialists.

RESULTS

The participants were asked to assess all the intraoral images and subjectively score them on a scale of one to ten, with one being very poor and ten being excellent, considering the sharpness, color, brightness, contrast, and overall quality of the image. The general dentists rated the images taken with a 90-mm macro lens and ring flash as the best quality photographs. Images obtained using an 18-55 mm lens and ring LED received significantly lesser scores and were graded good by dentists.

CONCLUSION

This combination of lens and flash may prove a valuable investment in the long-term aiding in excellent dental images for diagnosis and treatment monitoring.

Psychological health of postmenopausal women: a bibliometric analysis in the recent decade

The aim of this study is to analyze the publication trends on the psychological health of postmenopausal women by performing a bibliometric and visualization analysis that can be used as a foundation for understanding current and future research plans. Publications were retrieved from Dimensions database from 2012 to June 2022. VOSviewer software was used for data mining and visualization. A total of 1718 papers were selected by keyword search and delimiting criteria. To evaluate the productive nations, authors, journals, articles and frequent joint citations, citation analysis, author keyword co-occurrence analysis, co-authorship analysis and co-citation analysis were performed. Results depict that the USA contributed the most papers (n = 457). Maximum articles (n = 192) were published in 2021. The highest number of articles are published in Menopause: The Journal of the North American Menopause Society and Climacteric: The Journal of the International Menopause Society. Out of the top 10 contributing organizations in the field, six organizations were from the USA. R. Nappi of Italy is the most productive author with 20 articles and 1138 citations. From the point of average citations per article, H. Joffe has the highest score (71.5). The data reported in this analysis contribute to discussions about the development, growth and current state of psychological health of postmenopausal women as well as its impact. These findings offer helpful guidance for researchers in choosing their potential fields of study and integrating different approaches to solve complicated issues, finding potential co-authors and choosing the right institutions for supporting academic studies or collaborative research.

UNVEILING THE COMPLEX ROLE OF NF-ΚB IN ALZHEIMER'S DISEASE: INSIGHTS INTO BRAIN INFLAMMATION AND POTENTIAL THERAPEUTIC TARGETS

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline and dementia. One of the major pathologies underlying AD is chronic neuroinflammation mediated by microglia and astrocytes in the brain. The nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signalling pathway is a key regulator of inflammation and has been implicated in the neuroinflammatory processes associated with AD. This review comprehensively summarizes current findings on the complex role of NF-κB signalling in AD pathogenesis. The canonical and non-canonical NF-κB activation pathways are described, along with evidence from human studies and animal models demonstrating increased NF-κB activity in AD brains. The deleterious effects of NF-κB-mediated neuroinflammation are discussed, including the upregulation of inflammatory cytokines, chemokines, and enzymes that exacerbate neuronal damage over time. Targeting the NF-κB pathway is proposed as a promising therapeutic approach to dampen neuroinflammation in AD. Preclinical studies utilizing genetic or pharmacological inhibition of NF-κB are reviewed, and key challenges in translating these findings to clinical applications are analyzed. Overall, this review unveils the multifaceted contributions of NF-κB signalling to AD neuropathology and highlights anti-neuroinflammatory NF-κB modulation as a potential avenue for future AD treatments. Further research is warranted to fully elucidate the complex interactions between NF-κB and AD pathogenesis.

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.

Estimating motor unit numbers from a CMAP scan: Repeatability study on three muscles at 15 centres

OBJECTIVE

To assess the repeatability and suitability for multicentre studies of MScanFit motor unit number estimation (MUNE), which involves modelling compound muscle action potential (CMAP) scans.

METHODS

Fifteen groups in 9 countries recorded CMAP scans twice, 1-2 weeks apart in healthy subjects from abductor pollicis brevis (APB), abductor digiti minimi (ADM) and tibialis anterior (TA) muscles. The original MScanFit program (MScanFit-1) was compared with a revised version (MScanFit-2), designed to accommodate different muscles and recording conditions by setting the minimal motor unit size as a function of maximum CMAP.

RESULTS

Complete sets of 6 recordings were obtained from 148 subjects. CMAP amplitudes differed significantly between centres for all muscles, and the same was true for MScanFit-1 MUNE. With MScanFit-2, MUNE differed less between centres but remained significantly different for APB. Coefficients of variation between repeats were 18.0% for ADM, 16.8% for APB, and 12.1% for TA.

CONCLUSIONS

It is recommended for multicentre studies to use MScanFit-2 for analysis. TA provided the least variable MUNE values between subjects and the most repeatable within subjects.

SIGNIFICANCE

MScanFit was primarily devised to model the discontinuities in CMAP scans in patients and is less suitable for healthy subjects with smooth scans.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Kinesio taping with ballistic six plyometric training on speed, accuracy, target and joint proprioception in fast bowlers with glenohumeral instability

Cricket is one of the most popular international sports played worldwide. Ballistic six plyometric training improves throwing activity in throwing sports, improves rotator cuff muscular strength, and prevents and reduces the risk of shoulder injury associated with overhead pitching. Kinesiotaping is used in rehabilitation, as a treatment for sportsrelated injuries, and as a means of injury prevention. The objective of the study was to compare the combined effect of kinesiotaping with ‘ballistic six plyometric training’ and with ballistic six plyometric training alone on speed, accuracy, target and joint proprioception in fast bowlers with mild glenohumeral joint instability. Thirty male semiprofessional fast bowlers in the age group of 20-30 years were included in this study and randomly divided into two groups: group A and group B with 15 players in each group. Group A received kinesiotaping along with ballistic six plyometric training, whereas group B was only given ballistic six plyometric training. Both groups also performed conventional upper extremity workouts. All players were evaluated for bowling speed, accuracy, target and joint proprioception (internal rotation & external rotation) with a radar gun, cricket specific bowling accuracy test, no. of balls hit stump in an over and inclinometer, respectively. Both groups improved significantly at the end of week 8, however, group B showed significant difference for bowling speed, accuracy, target and joint proprioception (P<0.05). Rehabilitation protocol comprising of combined kinesiotaping, plyometrics along with conventional protocol can be beneficial in enhancing performance related variables, i.e. bowling speed, accuracy and target in fast bowlers with mild glenohumeral instability.

"Clinical Efficacy of Mycophenolate Mofetil versus Levamisole Therapy in Frequently Relapsing and Steroid Dependent Childhood Nephrotic Syndrome" - A retrospective comparative analysis

BACKGROUND

Children with Frequently relapsing (FR) or Steroid dependent (SD) Nephrotic Syndrome (NS) often develop side effects of corticosteroids. Various steroid-sparing agents are in practice, but only a few studies exist so far which have compared the safety and efficacy of these two commonly used agents.

METHODS

We did a retrospective medical records review of children with FRNS or SDNS who had Levamisole or MMF as a steroid-sparing agent with a minimum follow-up period of 12 months. The aim was to compare the course of our patients on MMF and Levamisole. Our primary objective was to determine the number of children in sustained remission and those with the infrequently relapsing course on Levamisole and MMF and, the median time to relapse in months in the two groups. The secondary objective was to compare time to first relapse and number of relapses in FRNS and SDNS group children on MMF and Levamisole.

RESULTS

A total of 88 children (34% female) with diagnosis FR/SDNS (44 each) were included in the study. Thirty-nine patients took Levamisole, while forty-nine received MMF therapy. The median age of presentation at the relapsing course was 4.2 years. The proportion of children with sustained remission or infrequent relapsing (IFR) course on MMF was 73.6%, compared to 48.71% on Levamisole (p-value 0.015). Also, the median time to first relapse was 12 months (24, 1.5) and 4.5 months (24, 1) on respective medications.

CONCLUSIONS

Clinical outcome was superior in the MMF group than Levamisole, especially in SDNS patients, and also MMF was more efficacious in maintaining sustained remission. This article is protected by copyright. All rights reserved.

Infectious complications in children with nephrotic syndrome: Can they be prevented?

Background

Sixty percent of children with nephrotic syndrome have frequently relapsing or steroid-dependent course. Serious infections like peritonitis, cellulitis, pneumonia etc. and anasarca with reduced urine output and complications there of including acute kidney injury and thromboembolism contribute significantly to morbidity and mortality in these children.

Methods

Questionnaire-based module to study infectious complications in children with nephrotic syndrome was circulated through survey monkey portal to paediatric nephrologists in our country. Twenty-two responded. Forty percent said that they saw patients with severe infections once a month. Fish bone analysis conducted on such patients reporting to our centre over next 3 months revealed that only 22% regularly monitored urine protein by dipstick. We proposed that reduction in time to report relapse by regularly monitoring urine protein could reduce complications in these children. Six urine protein dipsticks were handed over to patients who presented >7 days since relapse or with severe infection or anasarca in the last 1 year. These children were followed up for the next 1 year and given six more urine dipsticks every 3 months.

Results

Twenty-three patients were given urine protein dipsticks. Nine of them had 12 severe complications in the previous 6 months. None had any serious infections/anasarca on follow-up. Sixteen new patients had 14 serious complications in this time.

Conclusions

Early detection of relapse by home monitoring of urine protein by dipsticks was effective in significantly reducing the number of patients with severe infections and anasarca with reduced urine output.

A cross sectional survey on physical fitness, mental health and associated factors in mothers of children with special needs

Mothers are the primary caregivers of a child. While caring for a special needs child, workload of caring increases by manifold and taking care of these children increases physical & mental overload. There is a dearth of studies that have objectively evaluated mental health and fitness of this group. To study status of physical fitness, mental health and associated factors in mothers of special needs children a cross-sectional survey done on 100 mothers of special needs children from special schools in the Gurugram District, Haryana, India. The Harvard Step test was used to evaluate cardiac fitness. Standard tests were used to evaluate different components of musculoskeletal fitness. Depression was assessed by Beck Depression Inventory. Descriptive statistics were used for data analysis. The Karl Pearson correlation test was used to identify correlations between mental health and fitness components and sociodemographic characteristics. Mean age and body mass index of mothers was 36.15±2.56 years and 27.4±3.25 kg/m2, respectively. 50% of the subjects were overweight, 89% scored poor in cardiopulmonary fitness, 63% had very poor muscle endurance, and 69% had average muscular flexibility. 81% of the mothers had symptoms of clinical depression. Inverse and significant correlation was present between depression and cardiorespiratory fitness (r=-0.197), strength (r=-0.242), and endurance (r=0.209). Income, total number of children and duration of care giving were inversely correlated with depression. Positive correlation was found between type of disability and depression. There was an overall decrement in cardiorespiratory and musculoskeletal fitness. Mental health was found to be poor with a large percentage of participants showing symptoms of depression.

Prospective machine learning CT quantitative evaluation of idiopathic pulmonary fibrosis in patients undergoing anti-fibrotic treatment using low- and ultra-low-dose CT

AIM

To compare the machine learning computed tomography (CT) quantification tool, Computer-Aided Lung Informatics for Pathology Evaluation and Ratings (CALIPER) to pulmonary function testing (PFT) in assessing idiopathic pulmonary fibrosis (IPF) for patients undergoing treatment and determine the effects of limited (LD) and ultra-low dose (ULD) CT on CALIPER performance.

MATERIALS AND METHODS

Thirty-eight IPF patients underwent PFT and standard, LD, and ULD CT. CALIPER classified each CT voxel into either vessel-related structures (VRS), normal, reticular (R), honeycomb (HC) or ground-glass (GG) features. CALIPER-derived interstitial lung disease (ILD) extent represented the sum of GG, R and HC values. Repeated-measures correlation coefficient (ρ_rm) and 95% confidence interval (CI) evaluated CALIPER features correlation with PFT. Lin's concordance correlation coefficient (CCC) assessed concordance of CALIPER parameters across different CT dosages.

RESULTS

Twenty patients completed 12 months of follow-up. CALIPER ILD correlated significantly with percent predicted (%) forced vital capacity (FVC) and forced expiratory volume in 1 second (%FEV1; p=0.004, ρ_rm -0.343, 95% CI [-0.547, -0.108] and 0.008, -0.321, [-0.518, -0.07], respectively). VRS significantly correlated with %FVC and %FEV1 (p=0.000, ρ_rm -0.491, 95% CI [-0.685, -0.251] and -0.478, 0.000, [-0.653, -0.231], respectively). There was near perfect LD and moderate ULD concordance with standard dose CT for both ILD (CCC 0.995, 95% CI 0.988-0.999 and 0.9, 0.795-0.983, respectively) and VRS (CCC 0.989, 95% CI 0.963-0.997 and 0.915, 0.806-0.956, respectively).

CONCLUSIONS

CALIPER parameters correlate well with PFTs for evaluation of IPF in patients undergoing anti-fibrotic treatment without being influenced by dose variation. CALIPER may serve as a robust, objective adjunct to PFTs in assessing anti-fibrotic treatment related changes.

Utility of glomerular morphometry in diagnosing pediatric renal disease

BACKGROUND

Morphometry has now become a useful adjunct to the diagnostic armamentarium of light, immunofluorescence, and electron microscopy, as it provides a deep insight into quantitative parameters of nephropathies. There has been a limited study on its utility especially in diagnosing pediatric renal diseases. This study is probably the first in India to assess the contribution of this diagnostic modality in pediatric renal disease to the best of authors' knowledge.

METHODS

It's a retrospective cross-sectional study covering a period of 05 years at a tertiary care hospital. The study includes 28 cases of pediatric (age till 14 years) nephropathies. The diseases were divided into two groups-nephrotic presentation and nephritic presentation. Glomerular morphometry was performed and mean was calculated for Bowman's capsule area, glomerular capillary tuft area, and Bowman's space area; for the three groups, respectively. Renal parameters serum creatinine, blood urea, 24 h urine protein were studied along with hemoglobin and serum cholesterol for the cases. Data were analyzed using SPSS software, version 25, for one-way ANOVA comparing mean in the three groups.

RESULTS

We found a positive and significant correlation between Bowman's capsule area with proteinuria, blood urea, and serum creatinine. There was positive and significant correlation between glomerular capillary tuft area and serum creatinine and Bowman's space area and proteinuria in both the groups.

CONCLUSION

Glomerular morphometry may contribute to the diagnosis of some glomerulopathies and the association between glomerular morphometric parameters and laboratory data may promote better understanding of the prognosis of these patients.

The Canadian Neuromuscular Disease Registry 2010-2019: A Decade of Facilitating Clinical Research Througha Nationwide, Pan-NeuromuscularDisease Registry

We report the recruitment activities and outcomes of a multi-disease neuromuscular patient registry in Canada. The Canadian Neuromuscular Disease Registry (CNDR) registers individuals across Canada with a confirmed diagnosis of a neuromuscular disease. Diagnosis and contact information are collected across all diseases and detailed prospective data is collected for 5 specific diseases: Amyotrophic Lateral Sclerosis (ALS), Duchenne Muscular Dystrophy (DMD), Myotonic Dystrophy (DM), Limb Girdle Muscular Dystrophy (LGMD), and Spinal Muscular Atrophy (SMA). Since 2010, the CNDR has registered 4306 patients (1154 pediatric and 3148 adult) with 91 different neuromuscular diagnoses and has facilitated 125 projects (73 academic, 3 not-for-profit, 3 government, and 46 commercial) using registry data. In conclusion, the CNDR is an effective and productive pan-neuromuscular registry that has successfully facilitated a substantial number of studies over the past 10 years.

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.

Impact of early (&lt;24h) versus delayed (&gt;24h) intervention in patients with non ST segment elevation myocardial infarction (an observational study of 20882 patients)

Background

In patients presenting with non ST-segment elevation acute coronary syndromes (NSTE-ACS) an invasive approach has been shown to be superior to conservative management.

Purpose

We aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention.

Methods

We examined the impact ofearly (≤24h) versus delayed (&gt;24h) intervention in a large observational cohort of 20882 consecutive patients with acute NSTE myocardial infarction (NSTEMI) treated with PCI between 2005 and 2015 at 9 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching.

Results

Mean age was 64.5±12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24h.Patients treated within 24h were slightly younger (62.8±12.8 vs. 65.2±12.6, p&lt;0.001), most commonly male (76% vs. 72.9%, p&lt;0.001) and were more frequently ventilated (2.3% vs. 1.4%, p&lt;0.001) and in cardiogenic shock (3.6% vs. 1.4%, p&lt;0.001) with dynamic changes on their ECG (84.5% vs. 76.1% p&lt;0.001). At a median follow up of 4.2 years (interquartile range 1.8 to 7) 17.7% of patients had died. Estimated 5-year survival in patients treated within 24h was 84.6% vs. 81% for those treated &gt;24h following their presentation (p&lt;0.001). This survival benefit remained following adjustment for confounders; HR (delayed vs. early management)1.11 (95% CI 1.003 to 1.23, p=0.046). In the propensity matched cohort of 4356 patients in each group, there remained a trend for higher survival in the early intervention group (p=0.061).

Conclusions

Notwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24h) may improve mid term survival.

Figure 1

Funding Acknowledgement

Type of funding source: None

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study

BACKGROUND

Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management.

METHODS

This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially.

RESULTS

A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates.

CONCLUSION

Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions

Purpose

Type 1 diabetes (T1D) requires a holistic approach and continuous care. The current COVID-19 pandemic has made the health care professionals realise its challenges even more ardently than in the normal times. In a country like India with its huge population burden and a significant number of people having T1D, the risk of COVID-19 in people having T1DM is considerably high.

Methods

In this article, we are sharing our practical experiences of problems faced by children and adolescents having T1DM during the past 2 months of lockdown.

Results

We have classified the challenges into 3 broad categories based on diabetes self-management, healthcare system and psychosocial aspects. We have tried to provide precise, comprehensive and region specific solutions to these challenges. Solutions briefly include maintaining the supply chain of essentials like insulin, syringes and glucose meter strips to psychological support, financial aid and support for hospitalization in case of COVID-19 itself or diabetes complications including diabetic ketoacidosis.

Conclusions

Children and adolescents having T1DM require special care and attention during this period of COVID-19 pandemic because of various challenges as discussed. Our proposed solutions may help them overcome these problems and help them in better diabetes management during such emergency situations.

Primary Sjogren's syndrome manifesting with distal renal tubular acidosis and severe metabolic bone disease

Sjogren's syndrome (SS) is a chronic, autoimmune, inflammatory disorder affecting primarily the salivary and lacrimal glands with potential for systemic involvement. The disease predominantly occurs in women in the age group of 35-45 years and is relatively rare in children. It mainly affects salivary and lacrimal glands with potential for systemic involvement. Children presenting with the severe metabolic bone disease at the very outset has not been reported in the paediatric literature. We report a 13-year-old girl who presented with pain in multiple large joints with predominant involvement of hip joints leading to difficulty in walking for the past 6 months and unintentional weight loss of the same duration. Investigations revealed distal renal tubular acidosis with severe metabolic bone disease as an extra-glandular manifestation of primary SS.

Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Rationale, study design and methodology of the LANDMARC trial: a 3-year, pan-India, prospective, longitudinal study to assess management and real-world outcomes of diabetes mellitus

AIM

India contributes towards a large part of the worldwide epidemic of diabetes and its associated complications. However, there are limited longitudinal studies available in India to understand the occurrence of diabetes complications over time. This pan-India longitudinal study was initiated to assess the real-world outcomes of diabetes across the country.

METHODS

The LANDMARC study is the first prospective, multicentre, longitudinal, observational study investigating a large cohort of people with type 2 diabetes mellitus across India over a period of 3 years. The primary objective of this ongoing study is to determine the proportion of people developing macrovascular diabetes complications over the duration of the study (36 months ± 45 days) distributed over seven visits; the secondary objective is to evaluate microvascular diabetes complications, glycaemic control and time-to-treatment adaptation or intensification. Overall, 6300 participants (aged 25-60 years) diagnosed with type 2 diabetes for at least 2 years will be included from 450 centres across India. Data will be recorded for baseline demographics, comorbidities, glycaemic measurements, use of anti-hyperglycaemic medications and any cardiovascular or other diabetes-related events occurring during the observational study period.

CONCLUSIONS

The LANDMARC study is expected to reveal the trends in complications associated with diabetes, treatment strategies used by physicians, and correlation among treatment, control and complications of diabetes within the Indian context. The findings of this study will help to identify the disease burden, emergence of early-onset complications and dose titration patterns, and eventually develop person-centred care and facilitate public health agencies to invest appropriate resources in the management of diabetes. (Trial Registration No: CTRI/2017/05/008452).

Type B lactic acidosis due to Warburg effect in a child presenting with T cell acute lymphoblastic leukaemia: a milder phenotype

Lactic acidosis (LA) is characterised by persistently increased blood lactate >5 mmol/L. Type A LA due to anaerobic glycolysis is frequently seen during management of haematological malignancies. A rare form of LA known as type B LA, which occurs as a result of metabolic dysregulation at cellular level has been described recently. This has been reported to be because of Warburg effect (WE) or aerobic glycolysis, which is seen in cancerous cells as they rely on aerobic glycolysis rather than oxidative phosphorylation for energy generation. Presence of type B LA at initial presentation of haematological malignancies is a poor prognosticating factor and has rarely been reported in children. We present a child with T cell acute lymphoblastic leukaemia with mild phenotype of type B LA due to WE. She responded dramatically to definitive chemotherapy and tolerated intensive phase of chemotherapy without any significant morbidity.

Th17 cells increase in RRMS as well as in SPMS, whereas various other phenotypes of Th17 increase in RRMS only

Background

The nature and extent of inflammation seen in multiple sclerosis (MS) varies throughout the course of the disease. Changes seen in CD4+ T-helper cells in relapsing–remitting (RR) MS and secondary progressive (SP) MS might differ qualitatively and/or quantitatively.

Objective

The objective of this paper is to study the frequencies of all major CD4+ T-helper subtypes – Th17, Th22 and Th1 lineage cells – in relapse, remission and secondary progression alongside CCR6 status, a chemokine receptor involved in migration of these cells into the central nervous system.

Methods

We compared 100 patients (50 RRMS and 50 SPMS) and 50 healthy volunteers and performed flow cytometric analysis of lymphocytes in blood samples.

Results

We demonstrated raised frequencies of various cell types along the Th17 axis; Th17, Th17.1 (IL-17+ interferon gamma+) and dual IL-17+ IL-22+ cells in RRMS. Th22 and CCR6+ Th1 cells (nonclassical Th1) were also increased in RRMS. All these cells were CCR6+. Only Th17 frequencies were elevated in SPMS.

Conclusions

Increased frequencies of Th17 cells are implicated both in RRMS and SPMS. The CCR6 pathway includes Th17, Th22 and Th1 nonclassical cells, of which Th22 and Th1 cells represent the greatest subsets in MS.