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Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients.Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.

Chronic arsenic toxicity from Ayurvedic medicines.

Background  Ayurvedic medicines are known to contain arsenic and concentrations up to toxic levels have been reported in certain formulations. However, clinical disease due to arsenic containing ayurvedic medicines has rarely been reported. We seek to highlight the existence of toxic levels of arsenic in certain ayurvedic preparations that can produce serious systemic manifestations.

INCLEN diagnostic tool for autism spectrum disorder (INDT-ASD): Development and validation

ObjectiveTo develop and validate INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD).DesignDiagnostic test evaluation by cross sectional designSettingFour tertiary pediatric neurology centers in Delhi and Thiruvanthapuram, India.MethodsChildren aged 2–9 years were enrolled in the study. INDT-ASD and Childhood Autism Rating Scale (CARS) were administered in a randomly decided sequence by trained psychologist, followed by an expert evaluation by DSM-IV TR diagnostic criteria (gold standard).Main outcome measuresPsychometric parameters of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency.Results154 children (110 boys, mean age 64.2 mo) were enrolled. The overall diagnostic accuracy (AUC=0.97, 95% CI 0.93, 0.99; P<0.001) and validity (sensitivity 98%, specificity 95%, positive predictive value 91%, negative predictive value 99%) of INDT-ASD for Autism spectrum disorder were high, taking expert diagnosis using DSM-IV-TR as gold standard. The concordance rate between the INDT-ASD and expert diagnosis for’ ASD group’ was 82.52% [Cohen’s κ=0.89; 95% CI (0.82, 0.97); P=0.001]. The internal consistency of INDT-ASD was 0.96. The convergent validity with CARS (r = 0.73, P= 0.001) and divergent validity with Binet-Kamat Test of intelligence (r = −0.37; P=0.004) were significantly high. INDT-ASD has a 4-factor structure explaining 85.3% of the variance.ConclusionINDT-ASD has high diagnostic accuracy, adequate content validity, good internal consistency high criterion validity and high to moderate convergent validity and 4-factor construct validity for diagnosis of Autistm spectrum disorder.

Hepatic technetium‐99m‐mebrofenin iminodiacetate scans and serum γ‐glutamyl transpeptidase levels interpreted in series to differentiate between extrahepatic biliary atresia and neonatal hepatitis

Hepatic technetium‐99m‐mebrofenin iminodiacetate (99mTc‐mebrofenin IDA) scans and serum γ‐glutamyl transpeptidase (GGTP) have high sensitivity for extrahepatic biliary atresia (EHBA). This study was based on the hypothesis that the interpretation of results of 99mTc‐mebrofenin IDA scans and serum GGTP levels in series would result in a reduction of the false positivity observed with these tests individually. The aetiology of neonatal cholestasis in 132 study patients was: 25% (33/132) EHBA, 45.5% (60/132) neonatal hepatitis (NH) with an identifiable cause and 19.7% (26/132) idiopathic NH. Of the various clinical, biochemical and imaging parameters that were significantly different between patient groups, sensitivity for EHBA was: serum GGTP ≥ 150 IU 1−1(100%), 99mTc‐mebrofenin IDA scans (100%), pale stools (82.8%) and total serum bilirubin ≥ 12mg d1−1 (66%). However, specificity ranged from 48.5 to 79%. Of the 63 patients who had non‐excreting IDA scans, operative cholangiograms could be avoided on the basis of a specific aetiological diagnosis of NH, made concurrently, in only 9 infants. The rest (54) underwent operative cholangiograms; 21 (39%) of these had patent biliary trees and therefore underwent the procedure unnecessarily. If serum GGTP (<150 IU 1−1) had been used as a screen after IDA scanning in these 54 patients, operative cholangiograms could have been avoided in another 12 patients and thereafter only 9/42 (21%) of the operative cholangiograms would have been considered unnecessary.

Esophageal and gastric vasculature in children with extrahepatic portal hypertension Evaluation by intravenous CT portography

PURPOSE To compare the findings related to esophageal/gastric varices and congestive gastropathy on intravenous computed tomography (CT) portography (CTP) and upper gastrointestinal endoscopy (UGIE) in children with extrahepatic portal venous obstruction (EHO) presented with hematemesis. METHODS/MATERIALS Fifty pediatric patients (age < 15 years) with EHO (initially diagnosed on abdominal ultrasound) presented with hematemesis and underwent UGIE and intravenous CTP using a helical CT scanner. Axial sections of 2 mm each were obtained with a collimation of 2 mm and a table feed of 3 mm. CTP findings on these axial sections were compared with UGIE (gold standard). RESULTS The sensitivity of CTP for detection of esophageal varices, gastric varices, and gastropathy was 32/33 (97%), 38/40 (95%), and 30/32 (93%), respectively. CTP showed false positivity as well, which was 5/17 (29%), 2/10 (20%), and 13/17 (76%) for esophageal varices, gastric varices, and gastropathy, respectively. On follow-up UGIE, the endoscopic features appeared in 14/19 (74%) of false positive patients. Therefore, false positivity for all the parameters on CTP when compared to the initial UGIE represented the changes in vasculature before they were endoscopically manifest. CONCLUSIONS CTP was likely to pick up changes in esophageal and gastric vasculature earlier than UGIE in children with EHO presented with hematemesis.

Leucocyte migration inhibition in cow's milk protein intolerance

ABSTRACT. The leucocyte migration inhibition (LMI) was determined in an assay after in vitro challenge with beta‐lactoglobulin. The assay was considered positive when migration inhibition index was greater than 20 % (mean +3 SD of healthy infants). Ninety‐eight infants with protracted diarrhoea and failure to thrive, 16 healthy, 12 malnourished, and 16 infants suffering from acute gastroenteritis were studied. Of the 98 patients with protracted diarrhoea, 12 fulfilled Goldmans criteria for cows milk protein intolerance, 63 had lactose malabsorption, and in 15 no associated causative factor was identified. The mean index of migration inhibition in the cows milk allergic group (58.83 ± 11.98) was higher than in healthy controls (8.25 ± 3.91), the difference being statistically significant (p< 0.05). The test was positive in all patients with caws milk protein intolerance. The assay was also positive in four other patients suffering from protracted diarrhoea, two of whom had lactose malabsorption. All the infants with acute gastroenteritis and malnutrition had values within the normal range. The migration inhibition index in five patients with cows milk intolerance had declined to 24.74 ± 4.87 in assays performed 1‐6 weeks after return of clinical tolerance to cows milk (p< 0.05) but the test was still within the postive range in three of the five infants. These results suggest that this cell mediated immune assay is a sensitive test for the diagnosis of cows milk protein intolerance in infants. The specificity needs to be reassessed in the light of more objective criteria for the diagnosis of cows milk protein intolerance.

Hepatitis B immunization in low birthweight infants: do they need an additional dose?

Aim: To determine the influence of gestation and weight on the development of protective anti‐HB levels and geometric mean titres after three doses of HBV vaccine and to ascertain the need for a fourth dose in low birthweight infants. Methods: Hepatitis B vaccine (Enivac HB, Panacea Biotec Ltd., India) was given to 82 preterm (PT) and 60 term intrauterine growth‐retarded (T‐IUGR) infants at birth and at 6, 10 and 14 wk of life. Results: Protective anti‐HB levels (>10 mIU/ml) were reached in 86.6% (71/82) of PT infants and 96.7% (58/60) of T‐IUGR infants after three doses of HBV vaccine (p= 0.044). The odds of having a protective response after the third dose of HBV vaccine was 1.25 (95% CI 1.02–1.53) with every one‐week increase in gestation (p= 0.032). Birthweight was not associated with the development of a protective immune response. After the third dose, only 66.7% (8/12) of the PT infants whose mothers had anti‐HB antibodies, developed protective anti‐HB levels compared with 90% (63/70) of those with no maternal antibodies (p= 0.028). In PT infants after the fourth dose, there was a significant increase in the proportion of infants with protective antibody levels (8.6%, 95% CI 0.6–16.6%) among those with no maternal antibodies and 12.2% overall (95% CI 6.0–21.3) (p= 0.031 to 0.002) over that reached with the third dose. Administration of the fourth dose to T‐IUGR infants did not confer such a benefit.

Streptococcus pyogenes meningitis

Group A Streptococcus (GAS) is a rare cause of meningitis. Although it has a high mortality, the condition is easily treatable if diagnosed early since the bacteria retains its sensitivity to many antimicrobials. The authors report here two cases of GAS meningitis along with a review of world literature.

Cost of curative pediatric services in a public sector setting.

Objective : To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level.Methods: The costing module developed by Children’s Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days.Results: The cost per out-patient visit was INR.20.2 (US

Whole-of-society monitoring framework for sugar, salt, and fat consumption and noncommunicable diseases in India.

0.44@1US