Grace Rebekah

Risk factors for otitis media among preschool, rural Indian children

OBJECTIVE To establish the role of various risk factors for otitis media among preschool, rural Indian children. METHODS A cross sectional study of 800 children was undertaken to determine the prevalence of otitis media. Thereafter, using a case control study design, all the cases and an equal number of controls were compared in terms of various common risk factors for otitis media. The 13 risk factors studied were age, sex, socioeconomic status (SES), nutritional status, balwadi attendance, duration of breast feeding, passive smoking, exposure to household smoke, persistent rhinorrhoea,positive throat culture, snoring, seasonal rhinitis and allergic rhinitis. Bivariate association between these risk factors and otitis media was studied using chi-square test of proportions. Multivariate logistic regression analysis was done by including the variables which were significant at p=0.35 in the bivariate analysis. RESULTS From the cross sectional study, the prevalence of otitis media was found to be 8.6%, roughly half the prevalence obtained 10 years previously from the same region. Otitis media with effusion (OME) was the commonest manifestation of otitis media (6%) with 3.8% having bilateral disease. Ear wax was seen in 27.5% of subjects. Eighteen (2.3%) children failed the screening audiometry test set at 40 dB HL. Sociodemographic factors among cases and controls were comparable. The prime risk factors for otitis media identified by bivariate analysis included persistent rhinorrhoea, snoring and seasonal rhinitis. On multivariate logistic regression analysis, persistent rhinorrhoea (p<0.01,O.R.=7.56, 95%C.I. 2.73 - 20.92), snoring (p=0.01,O.R.=4.89, 95% C.I.1.32 - 18.17), seasonal rhinitis(p=0.02, OR=5.93,95% CI=1.33-26.51) and passive smoking (p=0.04, O.R.=3.29, 95%C.I. 1.05-10.33) were found to be important risk factors for otitis media. Age, sex, SES, parental education, seasonal or allergic rhinitis, inadequate breast feeding and exposure to household smoke were not significant risk factors. CONCLUSIONS Otitis media continues to have a high prevalence among South Indian children. Persistent rhinorrhea, snoring, seasonal rhinitis and passive smoking are the chief risk factors for the disease. Measures to reduce the prevalence of otitis media by addressing these risk factors are urgently required.

Knowledge, attitudes and practices with respect to risk factors for otitis media in a rural South Indian community

OBJECTIVES (a) To study knowledge, attitudes and practices with respect to risk factors of otitis media in a rural South Indian Community where the prevalence of otitis media is high. (b) To discover the association between parental education, socioeconomic status (SES) and family type (nuclear or joint) with knowledge, attitudes and practices regarding risk factors for otitis media. METHODS Using a cluster sampling design, the caregivers of 150 children attending daycare were interviewed to note knowledge, attitudes and practices with respect to risk factors for otitis media. Data on level of education of the caregiver, house type (an indicator of SES) and type of family structure were noted. A questionnaire was administered to collect all the relevant data. Statistical analysis of the data obtained was performed to note frequencies. Correlations between sociodemographic parameters and knowledge, attitudes and practices were studied using Chi-square test of proportions. RESULTS Over 50% of the population showed knowledge deficits with regard to the various risk factors for otitis media. Caregivers from nuclear families were slightly less knowledgeable regarding lack of immunization and household smoke as risk factors for the disease. There was no correlation between any of the sociodemographic factors and attitudes. However, educated mothers were more likely than illiterate mothers to clean their childrens ears of wax on a regular basis with the belief that it would prevent ear disease (p=0.05). Treatment practices in the community were more or less uniform in that earache was either disregarded (26.4%) or treated with home remedies (67.2%) by most caregivers, while a doctors opinion was often sought for ear discharge (50%). Parents of higher SES were more likely to use home remedies than those of lower SES (p=0.008). CONCLUSIONS Sociodemographic factors as well as poor knowledge and attitudes and unhealthy practices with respect to risk factors of otitis media contribute to the high prevalence of otitis media in this rural South Indian community. Health education regarding risk factors and provision of accessible health care is essential to reduce the disease burden.

Phase Changing Material: An Alternative Method for Cooling Babies with Hypoxic Ischaemic Encephalopathy

Background: Therapeutic hypothermia for hypoxic ischaemic encephalopathy (HIE) has been proved effective. Standard equipment is expensive, while ice packs used in low resource settings are labour intensive and associated with wider temperature fluctuations. Objectives: To assess the feasibility of using phase changing material (PCM) as an alternative method for providing therapeutic hypothermia. Methods: We retrospectively analysed 41 babies with HIE who had been cooled with PCM (OM 32™ or HS 29™) to a target rectal temperature of 33-34°C. Rectal temperature was continuously monitored and recorded every hour. If the rectal temperature was >33.8°C, cool gel packs were applied, and if the temperature was <33.2°C, the baby was covered with sheets and the warmer output turned on till the temperature stabilized at 33.5°C. The units standard protocol for cooling was followed for monitoring and treatment. The outcome measures were stability and fluctuation of the rectal temperature and the need for interventions to maintain the target temperature. Results: The mean (±SD) temperature during the cooling phase was 33.45 ± 0.26°C. Throughout the cooling phase, the target temperature range was maintained in 96.2% of the time. There was no temperature reading <32°C. With HS 29, ice packs were not used in any baby, and the warmer was used for a median of 7 h (interquartile range 1.5-14). Conclusions: PCM provides a low cost and effective method to maintain therapeutic hypothermia. However, careful monitoring is required during induction and the rewarming phase to avoid hypothermia outside the therapeutic range.

Adaptive threshold segmentation of pituitary adenomas from FDG PET images for radiosurgery

In this study we have attempted to optimize a PET based adaptive threshold segmentation method for delineating small tumors, particularly in a background of high tracer activity. The metabolic nature of pituitary adenomas and the constraints of MRI imaging in the postoperative setting to delineate these tumors during radiosurgical procedures motivated us to develop this method. Phantom experiments were done to establish a relationship between the threshold required for segmenting the PET images and the target size and the activity concentration within the target in relation to its background. The threshold was developed from multiple linear regression of the experimental data optimized for tumor sizes less than 4 cm3. We validated our method against the phantom target volumes with measured target to background ratios ranging from 1.6 to 14.58. The method was tested on ten retrospective patients with residual growth hormone‐secreting pituitary adenomas that underwent radiosurgery and compared against the volumes delineated by manual method. The predicted volumes against the true volume of the phantom inserts gave a correlation coefficient of 99% (p<0.01). In the ten retrospective patients, the automatically segmented tumor volumes against volumes manually delineated by the clinicians had a correlation of 94% (p<0.01). This adaptive threshold segmentation showed promising results in delineating tumor volumes in pituitary adenomas planned for stereotactic radiosurgery, particularly in the postoperative setting where MR and CT images may be associated with artifacts, provided optimization experiment is carried out. PACS number: 87.57.nm, 87.57.uk

Epidemiology of nasopharyngeal colonization by S. pneumoniae in Indian infants in the first 2 years of life

BACKGROUND Streptococcus pneumoniae is a leading cause of invasive disease in developing countries like India. Although the 13 valent pneumococcal vaccine has already been introduced in the country, there is very little epidemiological data regarding S. pneumoniae colonization and antibiotic susceptibility in Indian infants. METHODS We studied serogroup/serotype (SGT) distribution and antibiotic susceptibility pattern of S. pneumoniae in unvaccinated Indian infants by performing monthly nasopharyngeal swabbing of a birth cohort for 2 years. RESULTS Colonization began soon after birth and was complete in the first year of life in the majority of those colonized. Carriage rates increased during winter (p<0.01) and in those with upper respiratory infection (URI) (p<0.01). The most frequently (76.1%) isolated SGT were 19, 6, 15, 23, 9, 35 and 10. Vaccine SGT accounted for 60.5% of all colonizers. Antibiotic resistance was maximum for cotrimoxazole (94.3%) and least for erythromycin (11.2%) with no penicillin resistance. Ten of the commonest SGT which cause invasive disease among Indian infants comprised 46.9% of the colonizers. Serogroups 1, 5, 45 and 12 which cause invasive disease in under-fives were not seen in this birth cohort in the first year. CONCLUSIONS S. pneumoniae colonization in Indian infants commences soon after birth and chiefly occurs in the first year of life. The 13 valent vaccine may protect against a little less than half the commonly seen invasive SGT of S. pneumoniae.

Risk Factors for Stress During Antenatal Period Among Pregnant Women in Tertiary Care Hospital of Southern India.

BACKGROUND The well-being of an infant may be affected when the mother is subjected to psychosocial stress during her pregnancy. Mothers exposed to stressful conditions were more prone for preterm birth than those without any stress. In this study perceived stress has been used as an indicator of levels of stress. There are very few studies published from developing countries on the levels of perceived stress and its causes in pregnant women. MATERIALS AND METHODS This study employed a cross-sectional assessment of pregnant women attending the outpatient services of a tertiary care hospital for regular antenatal check-up. Women not known to have any risk factors at 28 weeks to 34 weeks of pregnancy who agreed to participate in the study were interviewed to assess the perceived stress score. RESULTS Among the total patients 57.7% were primigravida and the mean score on perceived stress scale was 13.5±5.02. The majority of the group (102; 65.4%) scored higher than the mean value of total score on the perceived stress scale. Unplanned pregnancy and husbands employment status were associated with high levels of perceived stress in multivariate analysis in this set of women. CONCLUSION Individual as well as pregnancy related factors can contribute to perceived stress in pregnant women. With the established relationship between maternal mental health, pregnancy outcome and infant growth, the assessment and management of stress early in the pregnancy is crucial.

Can skin temperature replace rectal temperature monitoring in babies undergoing therapeutic hypothermia in low-resource settings?

In low-resource settings, where the majority of asphyxial deaths occur, the mandatory measuring of core temperature may not always be practical when practicing therapeutic hypothermia (TH). If a standardized measurement of skin temperature could replace core temperature monitoring, it would make cooling more feasible. In normothermic newborn, axillary temperature measurements are the standard of care (1). Further studies have shown that insulated back temperature using the zero heat flow method correlates well with rectal temperature and can be used as a measure of core temperature (2–4). However, none of the studies comparing the agreement of skin and rectal temperature included babies who were hypothermic. The only studies that have looked at cooled babies have used correlation as a measure, which does not mean that the agreement is within acceptable limits (5,6). The aim of our study was to look at the correlation and agreement of skin temperature with rectal temperature, postulating that skin temperature could replace rectal temperature monitoring in babies undergoing therapeutic hypothermia. This was a method comparison study conducted in a level 3 neonatal unit of a tertiary care teaching hospital in south India from November 2008 to August 2011. All babies who underwent whole-body cooling for perinatal asphyxia were included. The details of the inclusion criteria and the low cost method of cooling used have previously been described (7). The institutional review board, ethics committee approval and patient consent were obtained prior to cooling babies. In all babies who underwent therapeutic hypothermia, a rectal probe (Philips-ref no 21090A or Drager-ref no 4329848-08) to monitor core temperature was inserted 5 cm within the rectum and connected to a multi-parameter monitor [Philips Intellivue MP20 (Philips, Bobleign, Germany) or Drager vista XL (Drager, Telford, PA, USA)]. Temperature was continuously monitored and recorded every 15 min for 4 h and then subsequently every hour for 80 h until re-warming was completed. The skin temperature measured was either axillary temperature or insulated back temperature. In 20 babies, the axillary temperature was measured simultaneously at the time of the rectal temperature recording using an electronic thermometer [Terumo-C 27 (Terumo corporation, Shizuoka, Japan)], which was placed in the apex of the axilla, arms adducted and reading taken after 3 min. In the subsequent 20 babies, the insulated back temperature (zero heat flow method) was continuously monitored using a skin probe (Drager-ref no 7498921), which was placed lateral to the spine just below the level of the scapula and recorded at the same time as the rectal temperature. All data were recorded in the study form and entered into an excel spread sheet. Data were analysed using SPSS 16.0 for windows (SPSS Inc, Chicago, IL, USA). Linear regression analysis and correlation coefficients were calculated to assess the relation between rectal and skin temperature. Reliability analysis was performed using intraclass correlation (ICC). The primary outcome we looked at was the agreement between rectal and skin temperature measurements using the method suggested by Bland and Altman (8). A BlandAltman plot of bias (rectal minus skin temperature for each outcome at each time point) versus average of each pair of measurement was created. From this, the mean bias (accuracy) and the 95% limits of agreement (precision) were calculated. The limits of agreement are used to estimate where 95% of future differences of skin temperature measurements Acta Pædiatrica ISSN 0803–5253

Effect of Interleukin-28B polymorphism on Interleukin-28 expression and immunological recovery amongst HIV-1-infected individuals following antiretroviral therapy

Purpose: Type III interferon is well known to have diverse antiviral and immunomodulatory activities. Studies describing the association of interleukin (IL)-28 polymorphisms in treatment-experienced HIV participants are limited. This study was aimed to determine the association of IL-28B gene polymorphisms with immunological recovery in HIV patients on 6–9 months of antiretroviral therapy (ART). Methods: Eighty treatment-naive HIV patients were recruited, of which 48 patients were followed up after 6–9 months of ART. Whole blood samples were collected before and after 6–9 months of ART. CD4, CD8 and CD3 counts were enumerated flow cytometry. IL-28B polymorphisms (rs12979860 and rs8099917) were profiled by polymerase chain reaction (PCR)-restriction fragment length polymorphism. The IL-28 mRNA and plasma HIV-1 viral load were estimated using real-time PCR and plasma IL-28 level by ELISA. Results: The CD4, CD4/CD3%, IL-28 mRNA and reversal of CD4/CD8 ratio were significantly increased following 6–9 months of ART (P < 0.01). The rs12979860 CC genotype and rs12979860:rs8099917 (CC: TT) haplotype showed significant association with higher CD4+ T-cell count amongst treatment-naive HIV-infected individuals (P < 0.05). In addition, there was a significant association of rs12979860 CC genotype with increase in CD4/CD3% following 6–9 months of ART. IL-28 mRNA showed correlation with the HIV-1 viral load, and there was a significant increase in the IL-28 mRNA expression following 6–9 months of ART. Conclusion: Our preliminary findings suggest that IL-28 polymorphisms could influence both immunological recovery and therapeutic response in HIV infection. Hence, functional studies are warranted to understand the mechanistic basis of IL-28-mediated host genetic influence on HIV therapeutic response.

Comparison of Two Low-cost Methods of Cooling Neonates with Hypoxic Ischemic Encephalopathy

Background Several low-cost methods are used in resource-limited settings to provide therapeutic hypothermia in asphyxiated neonates. There is inadequate data about their efficacy and safety. This is a retrospective study comparing two low-cost cooling methods-frozen gel packs (FGP) and phase changing material (PCM). Results There were 23 babies in FGP and 45 babies in the PCM group. Induction time was significantly shorter with FGP than PCM (45 vs. 90 minutes; p -value < 0.001). Proportion of temperature readings outside the target range was significantly higher (9.8% vs. 3.8%; p -value < 0.001) and fluctuation of core body temperature was wider (standard deviation of target temperature 0.4 °C vs. 0.28 °C) in the FGP group, compared with PCM group. Conclusion Both FGP and PCM are effective and safe, comparable with standard servo-controlled cooling equipment. PCM has the advantage of better maintenance of target temperature with less nursing input, when compared with FGP.

Utility of neutrophil volume conductivity scatter (VCS) parameter changes as sepsis screen in neonates.

Objective:The objective of this study was to determine changes in neutrophil volume conductivity scatter (VCS) parameters and their distribution widths (DW) in neonatal sepsis and to estimate their optimal cutoff levels using receiver operating characteristic (ROC) curves.Study Design:In a cohort of neonates evaluated for sepsis, blood counts and blood culture were performed initially, with repeat counts and C-reactive protein (CRP) done after 24 to 48 h. Neutrophil VCS parameters from both the initial and repeat blood counts were analyzed. Babies were classified as having blood culture-positive sepsis, probable sepsis (clinical course consistent with sepsis and CRP-positive, but culture-negative) and no sepsis (clinical course not compatible with sepsis, culture- and CRP-negative).Results:A total of 600 babies were included: 240 (40%) babies in the sepsis group and 360 (60%) babies in the control group. All the neutrophil VCS parameters and their DWs (except for low angle light scatter in the repeat counts) were significantly different between the two groups, with an area under curve in the ROC curve of >0.6 for most parameters. The five most significant VCS parameters (mean neutrophil volume (MNV), median angle light scatter (MALS), lower median angle light scatter (LMALS), MNV-DW and ALL-DW) had around 65 to 75% sensitivity and specificity. A combination of leukopenia, thrombocytopenia, MNV and LMALS had a likelihood ratio (LR)+ of 15.3 and LR− of 0.17. With a pre-test probability of 40%, post-test probability increased to 91% for a positive test and decreased to 10% for a negative test. A prospective validation study was performed recruiting an additional 60 babies, which showed similar results, assuring that the cutoffs were robust.Conclusion:Neutrophil VCS parameters cannot be considered as stand-alone tests to diagnose or rule out neonatal sepsis, but can be used in combination with other hematological screening tests to improve the diagnostic accuracy of the neonatal sepsis screen.