Suchetha Rao

Henoch–Schonlein purpura: An update

Abstract Henoch–Schonlein purpura (HSP), the commonest childhood vasculitis, is characterised by non-thrombocytopaenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. The peak incidence is between the ages of 4 years and 8 years with a male preponderance. Though the diagnosis is usually clinical, a tissue biopsy revealing leucocytoclastic vasculitis is helpful when the presentation is atypical. Renal involvement in the form of an immune complex glomerulonephritis is the most serious long-term complication. The aetiopathogenesis, classification, clinical features, relevant Indian data, and a stepwise management approach with corticosteroids and immunosuppressive agents per the renal histology are discussed.

Does institutional delivery help in improving infant and child health care practices and health promotion related parameters? A study from Bellary, Karnataka

Introduction Inspite of emphasis on institutional delivery, a considerable number of births are being conducted at home and by traditional birth attendant (TBA). Institutional delivery is hypothesized to improve the health seeking behavior and health care practices related to infant and child care. In this paper we report that in a poorly performing district institutional delivery does not seem to change the health care practices of the people. Methods The data presented here is a part of a larger two years long study funded by ICMR and conducted at Bellary and Dakshina Kannada district of Karnataka. The results reported pertain to the cross sectional community based house to house survey carried out among 2158 households at Bellary regarding births during the five-year period before survey to ever-married women. The Institutional Ethics Committee had approved this study. Results A total of 1010 deliveries were at the institution while 1148 deliveries took place at home, of which 891 deliveries were conducted by the dais. Majority of mothers who delivered with the help of a dai had not been explained about breastfeeding and its importance. Delayed breastfeeding beyond 2 hours after birth was seen in 38% of institutional deliveries as opposed to 62% home deliveries. Though 79% babies delivered at home were given pre-lacteal feeds, a large number (57%) of those delivered at institution also received pre-lacteal feeds. The weaning practices were also very similar in both the groups. Majority of the women delivered at home (by dais) had undergone antenatal check up by either a doctor (Private 41% and government 21%) or a nurse (12.7%). More than half of the houses where delivery was at home or by a dai were in close proximity (within 5Km in 62 %) to a health facility. Treatment seeking behavior for childhood illness was similar in the institutional and the home birth group. The majority went to private clinic or hospitals (55% home delivery vs 60% hospital) followed by chemist shop (without prescription) and alternate system of medicine. Discussion The health seeking behavior and health care practices depend on the beliefs and awareness among people. Availing antenatal care is hypothesised to promote institutional delivery but this did not seem to be the case in Bellary. Institutional deliveries too did not help in doing away with practices related to delayed breastfeeding and supplementary feeding as well as pre-lacteal feeds. Mere emphasis on institutional delivery seemed to be ineffective in changing the perception and beliefs of people leading to practices which may be harmful to child’s health. Non-utilization of health facilities for delivery in spite of proximity calls for a relook at the availability, affordability and quality of services at these facilities. Institutional delivery per se may not be the answer for infant and child care practices. Sustained efforts by means of campaigns and awareness activities coupled with the use of mass media may help in improving the health care practices. Health systems research and study of local traditions are needed before implementing a tailor-made strategy for improving the health care practices and behavior in a district/region. [509 words]

Public-Private Partnership in Health Care: A Comparative Cross-sectional Study of Perceived Quality of Care Among Parents of Children Admitted in Two Government District-hospitals, Southern India.

INTRODUCTION Perceived better quality of care draws lower socio-economic classes of Indians to more expensive private setups, leading to poverty illness poverty cycle. Urgent measures need to be taken to improve perceived quality of public hospitals. The present study compares the difference in perceived quality of care among parents of children admitted at two government district hospitals. MATERIALS AND METHODS A cross-sectional, comparative, questionnaire based study was conducted between February 2011 and February 2012 at Government medical college hospitals of two district headquarters in South-India: one with private-public-partnership (PPP-model); another directly operated by government - Public Hospital-model (PH-model). A total of 461 inpatients from the PH model hospital and 580 from the PPP model hospital were eligible. Patients who left against advice (LAMA) (n=44 in PH and 19 in PPP) and expired (n=25 in PH and 59 in PPP) were excluded. Fourteen incomplete forms from PH and 10 from PPP model hospital were also excluded. Responders rated perception on a 1-5 scale in each domain: accessibility of health-facility, time spent waiting, manner and quality of physician, manner and quality of nurse, manner and quality of supporting staff, perception of equipment, explanation of treatment details and general comfort. The responders also rated overall satisfaction on a 1-10 scale. In the 1-5 scale, rating≥4 in each domain was considered good. Rating≥8 in 1-10 scale was considered satisfaction. RESULTS Responders from PPP-model hospital were significantly more satisfied than those from PH-model {n=529 (91.2%) vs. n=148 (32.1%) p<0.001}. This was true even when controlled for age-group, sex, maternal education, family-type, days of hospital-stay and socioeconomic class {O.R.(CI) =23.58 (16.13-34.48); p<0.001} by binary logistic regression model. In the PPP-model hospital the time spent waiting for treatment {4.28(2.07-8.82), p<.001} and manner of support staff {3.64(1.02-12.99), p=0.04} significantly predicted satisfaction. In PH-model hospital explanation given regarding treatment details significantly predicted overall satisfaction {2.99(1.61-5.54), p<.001}. CONCLUSION Perceived quality of hospital care, as evidenced by the satisfaction and perception ratings of responders, was better in PPP-model hospital. This model could be emulated in developing countries to draw patients of lower socio-economic classes to tertiary-care public hospitals which are less expensive.

Biochemical Basis of Heterogeneity in Acute Presentations of Propionic Acidemia

Propionic acidemia (PA), an uncommon organic acidemia has varied clinical and metabolic presentation causing difficulty and delay in the diagnosis. We report a case of PA in an infant who presented with failure to thrive, acute encephalopathy due to severe hyperammonemia without acidosis and fungal sepsis. The biochemical basis of severe hyperammonemia is discussed.

Autoantibody profile in a cohort of South Indian children with Kawasaki disease

Objective: There is no clear data on autoantibody levels in Kawasaki Disease (KD) especially from the Indian Subcontinent. Aim: To look for the presence of organ nonspecific and organ specific antibodies to strengthen the search for an autoimmune cause of KD. We tested the presence of antinuclear antibody (ANA) and antithyroid microsomal antibody (TMA) in children with KD, 6 months after the acute phase. Anti Neutrophil Cytoplasmic Antibody (pANCA, cANCA), Anti Endothelial Cytoplasm Antibody (AECA) and Anti Smooth Muscle Antibody (SMA) was additionally tested in those with elevated titers of ANA and/or TMA. Materials and Methods: Prospective case-control study of 24 children with KD on follow up and an equal number of age and sex matched controls. Historical data about acute phase of illness was obtained from the medical records. After obtaining institutional ethics committee clearance and informed consent from the parents, blood was tested for ANA and TMA by the indirect immunofluorescence method (IIF), using a kit developed by Euroimmun. Positive samples were additionally tested for pANCA, cANCA, AECA and SMA. Relationship of autoantibody elevation and clinical course in the cases was determined. Results: The age of the study group was 4 ΁ 3.2 years. Incomplete KD was seen in 12.5% of the cases. Five cases (21%) had cardiac involvement. All but one with mitral and tricuspid regurgitation resolved after the acute phase of the disease. Only her ANA was elevated. Two children (8%) positive for TMA did not show any cardiac abnormalities. Further antibody testing was negative. All three children with elevated autoantibodies were females. (P value = 0.02: statistically significant). Conclusion: Elevated autoantibodies in three (12.5%) children after the acute phase may suggest the role of autoimmunity in the etiopathogenesis of KD, even though our observations were not statistically significant.

Influenza B virus triggering macrophage activation syndrome in an infant

Macrophage activation syndrome (MAS) is a potentially fatal complication caused by excessive activation and expansion of macrophages and T lymphocytes. It can be triggered by various infections and is characterized by the development of cytopenias, hyperferritinemia, liver dysfunction, and coagulopathy. We report a 10-month-old female infant with fever, convulsions, and hepatosplenomegaly. Laboratory data of bicytopenia, low erythrocyte sedimentation rate, and elevated liver enzymes suggested MAS. This was supported by the presence of hyperferritinemia with hypertriglyceridemia. MAS was triggered by influenza B virus. She responded to treatment with immunoglobulin and steroid.

Klippel-Trenaunay syndrome and type 1 neurofibromatosis: A chance association?

Klippel-Trenaunay syndrome and neurofibroma type I (NF1) are rare disorders with cutaneous and neurological features and not reported to be associated together. We report an 11-year-old female child who presented with extensive skin lesions, giant hemangioma and left lower limb hypertrophy. Her father had features of NF1. We report this case because of its rarity and need for long-term follow-up.