Rajiv Aggarwal

Changing profile of retinopathy of prematurity.

The aim of this study was to determine the evolving trends of retinopathy of prematurity (ROP) at a tertiary neonatal intensive care unit. In an ongoing screening programme for ROP, we estimated the incidence of ROP among at-risk neonates in a tertiary care unit. We compared our data over the last 12 months (1999-2000; period II) to the previously published data (1993-94; period I) to study changes in the spectrum of the disease. The overall incidence of ROP in period II was not significantly different from the incidence in period I (32 vs. 20 per cent, p > 0.05). However, a decreasing trend in the proportion of severe ROP (stage III) from 46 to 21 per cent in the later period was noted. The need for cryotherapy also dropped significantly compared with the earlier period (8 vs. 46 per cent respectively, p < 0.05). On multivariate analysis, apnea (p < 0.001; RR = 12.5; 95 per cent CI, 3.03-50.9; clinical sepsis (p < 0.001; RR = 5.7; 95 per cent CI, 1.6-20.7); and male sex (p < 0.001; RR = 6.3; 95 per cent CI 1.6-25.5) emerged as significant risk factors. Although the incidence of ROP is static, the more severe form of the disease (stage III) is showing a decline. Our data suggests that efficient management of apnea and sepsis may be crucial in further minimizing the risk of ROP.

Pediatric liver transplantation: A report from a pediatric surgical unit.

Background: Liver transplantation is well established worldwide as an effective treatment for end-stage liver disease in children. Acceptance in India has been slow because of considerations of cost, infections, inability to support long-term care, and non-availability of expertise. Aim: This study was designed to report our experience with pediatric liver transplantation. Materials and Methods: Twenty-eight children underwent liver transplantation. Results: Biliary atresia was the commonest indication (n = 15) followed by metabolic liver disease. Twenty-six children had living donor transplants, mothers being the donors in a majority of these. Common surgical complications included bile leaks (n = 3) and vascular problems (n = 6). Common medical complications included infections, acute rejection, and renal failure. Overall, patient survival was 71%, while that for the last 14 cases was 92%. All survivors are doing well, have caught up with physical and developmental milestones and are engaged in age appropriate activities. Conclusions: The study demonstrates the feasibility of a successful pediatric liver transplant program in our country.

Dandy-Walker malformation in Rubinstein-Taybi syndrome: a rare association.

A female infant is described with the rare association of Dandy-Walker malformation in Rubinstein-Taybi syndrome.

Organophosphate Poisoning Presenting as Acute Respiratory Distress

Sir, Organophosphate poisoning [OP] is a potentially fatal but completely treatable condition that is still very prevalent in our country. Early recognition is paramount in preventing fatality. Although rarely reported, it does occur in infants, where history may not be forthcoming and initial presentation often misleading. We report a case of aspiration pneumonia whose evolving symptomatology made us diagnose OP poisoning. A previously healthy baby presented with vomiting whilst breast feeding followed by respiratory distress and altered sensorium. No prior history of fever, respiratory illness, seizures or drug intake. On examination he was a well thriving infant, who was afebrile with severe respiratory distress. He had altered sensorium and was markedly hypotonic with small sluggishly reacting pupils. Emergency management was given and baby was intubated and ventilated. Empirical antibiotics for possible aspiration pneumonia and other supportive treatment was started. Blood counts, chest radiograph and metabolic profile were normal. In the next few hours his sensorium worsened, pupils became pin pointed and unreactive to light. Copious oropharyngeal secretions and diarrhea were also noted. This constellation of symptoms made us suspect cholinergic hyperactivity and a large dose of atropine was given, which did not produce pupil dilatation, suggesting OP poisoning [1]. To confirm cholinesterase [ChE] level [2] was done and was found to be less than 25% reference range. Atropine infusion was immediately instituted at 0.02 mg/kg/hour [5], titrated to drying of secretions. As the nature of OP compound unknown empirical dose of pralidoxime, 25 mg/kg was given to reactivate ChE enzyme [5]. In next 24 h baby showed good improvement in motor tone and power with drying of secretions, and was subsequently extubated. Retrospectively parents revealed that insecticide was sprayed around the house on that day and child most likely got exposed by inhalation. Atropine was continued for 3 days and then weaned over 24 h. Serial monitoring of ChE levels showed a steady rise in titers to normal. The baby was discharged after a week and parents were counseled on the hazards of environmental exposure to OP compounds. OP’s inhibit ChE activity and affect central and peripheral muscarinic and nicotinic receptors [2]. Unlike adults infants mainly present with acute CNS depression and are characterized by the absence of typical muscarinic effects including fasciculation and bradycardia. The pupil examination is the key [3] and pin point pupils with diarrhea at presentation, is described as a triage tool for early recognition in children [4]. As with our infant, periodic pupil examination helped clinch the diagnosis. Therapeutic trial of atropine and serum ChE levels helps to make the diagnosis, however no correlation between the level and severity is noted [2]. Treatment is aimed at decontamination, reversal of muscarinic signs with atropine and enzyme reactivation by oximes. Frequent atropine doses or as continuous infusion titrated to achieve drying of secretions is used. Single dose of pralidoxime, or in severe poisoning a continuous infusion is used. Oximes are continued for 24 h after symptoms resolve or restoration of normal serum ChE levels [5].

Scintigraphic scoring system for grading severity of gastro-esophageal reflux on 99mTc sulfur colloid gastro-esophageal reflux scintigraphy: A prospective study of 39 cases with pre and post treatment assessment

Aim: The study aimed at developing a scoring system for scintigraphic grading of gastro-esophageal reflux (GER), on gastro-esophageal reflux scintigraphy (GERS) and comparison of clinical and scintigraphic scores, pre- and post-treatment. Materials and Methods: A total of 39 cases with clinically symptomatic GER underwent 99mTc sulfur colloid GERS; scores were assigned based on the clinical and scintigraphic parameters. Post domperidone GERS was performed after completion of treatment. Follow up GERS was performed and clinical and scintigraphic parameters were compared with baseline parameters. Results: Paired t-test on pre and post domperidone treatment clinical scores showed that the decline in post-treatment scores was highly significant, with P value < 0.001. The scintigraphic scoring system had a sensitivity of 93.9% in assessing treatment response to domperidone, specificity of 83.3% i.e., 83.3% of children with no decline in scintigraphic scores show no clinical response to Domperidone. The scintigraphic scoring system had a positive predictive value of 96.9% and a negative predictive value of 71.4%. Conclusion: GERS with its quantitative parameters is a good investigation for assessing the severity of reflux and also for following children post-treatment.