Sunil Karande

Patterns of prescription and drug dispensing

Objective: To analyze the patterns of prescriptions and drug dispensing using World Health Organization core drug use indicators and some additional indices.Methods: Data were collected prospectively by scrutinizing the prescriptions written by pediatric resident doctors and by interviewing parents of 500 outpatient children.Results: The average number of drugs per encounter was 2.9 and 73.4% drugs were prescribed by generic name. Majority of drugs prescribed were in the form of syrups (60.8%). Use of antibiotics (39.6% of encounters) was frequent, but injection use (0.2% of encounters) was very low. A high number of drugs prescribed (90.3%) conformed to a model list of essential drugs and were dispensed (76.9%) by the hospital pharmacy. Certain drugs (5.7%) prescribed as syrups were not dispensed, although they were available in tablet form. Most parents (80.8%) knew the correct dosages, but only 18.5% of drugs were adequately labeled. No copy of an essential drugs list was available. The availability of key drugs was 85%.Conclusion: Interventions to rectify over prescription of antibiotics and syrup formulations, inadequate labeling of drugs and lack of access to an essential drugs list are necessary to further improve rational drug use in our facility.

Poor school performance

Education is one of the most important aspects of human resource development. Poor school performance not only results in the child having a low self-esteem, but also causes significant stress to the parents. There are many reasons for children to under perform at school, such as, medical problems, below average intelligence, specific learning disability, attention deficit hyperactivity disorder, emotional problems, poor socio-cultural home environment, psychiatric disorders and even environmental causes. The information provided by the parents, classroom teacher and school counselor about the child’s academic difficulties guides the pediatrician to form an initial diagnosis. However, a multidisciplinary evaluation by an ophthalmologist, otolaryngologist, counselor, clinical psychologist, special educator, and child psychiatrist is usually necessary before making the final diagnosis. It is important to find the reason(s) for a child’s poor school performance and come up with a treatment plan early so that the child can perform up to full potential.

Clinical and psychoeducational profile of children with specific learning disability and co-occurring attention-deficit hyperactivity disorder.

BACKGROUND Almost 10% of school-going children have specific learning disability (SpLD) in the form of dyslexia, dysgraphia and/or dyscalculia. Attention-deficit hyperactivity disorder (ADHD) occurs as a comorbidity in about 20% of these children. AIMS To document the clinical profile and academic history of children with SpLD and co-occurring ADHD. SETTINGS AND DESIGN Prospective observational study conducted in our clinic. MATERIALS AND METHODS From August to November 2004, 50 consecutively diagnosed children (34 boys, 16 girls) were included in the study. SpLD was diagnosed on the basis of psychoeducational testing. Diagnosis of ADHD was made by DSM-IV-revised criteria. Detailed clinical and academic history and physical and neurological examination findings were noted. STATISTICAL ANALYSIS Chi-square test or unpaired students t-test was applied wherever applicable. RESULTS The mean age of children was 11.4 years (+/-SD 2.5, range 7-17.1). Fifteen (30%) children had a significant perinatal history, 12 (24%) had delayed walking, 11 (22%) had delayed talking, 5 (10%) had microcephaly, 27 (54%) displayed soft neurological signs and 10 (20%) had primary nocturnal enuresis. There were no differentiating features between the two gender groups. Their academic problems were difficulties in writing (96%), inattentiveness (96%), difficulties in mathematics (74%), hyperactivity (68%) and difficulties in reading (60%). All children had poor school performance, 15 (30%) had already experienced class retention and 20 (40%) had developed aggressive or withdrawn behavior. CONCLUSION Children with SpLD and co-occurring ADHD need to be identified at an early age to prevent poor school performance and behavioral problems.

Autism: A review for family physicians

Autism is a complex neurodevelopmental disorder characterized by qualitative impairments in social interaction and communication, with restricted, repetitive, stereotyped patterns of behavior, interests and activities. These behaviors manifest along a wide spectrum and commence before 36 months of age. Diagnosis of autism is made by ascertaining whether the childs specific behaviors meet the Diagnostic and Statistical Manual of Mental Disorders-IV-Revised criteria. Its etiology is still unclear but recent studies suggest that genetics plays a major role in conferring susceptibility. Recent neuroimaging research studies indicate that autism may be caused by atypical functioning in the central nervous system, particularly in the limbic system: amygdala and hippocampus. In a third of autistic children, loss of language and/or social skills occurs during the second year of life, usually between 15 and 21 months of age. Comorbidity with mental retardation, epilepsy, disruptive behaviors and learning difficulty is not uncommon. Although there is currently no known cure for autism there is evidence to suggest that early intervention therapy can improve functioning of autistic children. Judicious use of psychotropic drugs is necessary to manage associated aggression, hyperactivity, self-mutilation, temper tantrums; but drugs are not a substitute for behavioral and educational interventions. The family physician can play an important role in detecting autism early, coordinating its assessment and treatment, counseling the parents and classroom teacher, and monitoring the childs progress on a long term basis.

The Proposed Changes for DSM-5 for SLD and ADHD: International Perspectives—Australia, Germany, Greece, India, Israel, Italy, Spain, Taiwan, United Kingdom, and United States

This article presents an international perspective of the proposed changes to the DSM-5 for learning disabilities (LD) and attention-deficit/hyperactivity disorders (ADHD) across ten countries: Australia, Germany, Greece, India, Israel, Italy, Spain, Taiwan, the United Kingdom, and the United States. We provide perspectives of the present situation for youth with LD and youth with ADHD and describe the legislation, prevalence rates, and educational systems that serve students with disabilities in the respective countries. We also present a discussion of the expected impact of the proposed changes for the diagnosis of LD and ADHD in each country.

Clinical and Psychoeducational Profile of Children with Borderline Intellectual Functioning

ObjectiveTo document the clinical profile and academic history of children with borderline intellectual functioning (“slow learners”); and to assess parental knowledge and attitudes regarding this condition.MethodsFrom November 2004 to April 2005, 55 children (35 boys, 20 girls) were diagnosed as slow learners based on current level of academic functioning and global IQ scores (71–84) done by the WISC test. Detailed clinical and academic history; and physical and neurological examination findings were noted. The parents were counseled about the diagnosis and the option of special education.ResultsThe mean age of slow learners was 11.9 years (±SD 2.3, range 8–17). Eighteen (32.7%) children had a significant perinatal history, 15 (27.3%) had delayed walking, 17 (30.9%) had delayed talking, 17 (30.9%) had microcephaly, 34 (61.8%) had presence of soft neurologic signs, and 10 (18.2%) were on complementary and alternative medication therapy. There were no differentiating features between the two gender groups. Their chief academic problems were difficulty in writing (92.7%), overall poor performance in all subjects (89.1%), and difficulty in mathematics (76.4%). Forty-six (83.6%) children had failed in examinations, 34 (61.8%) had experienced grade retention, and 32 (58.2%) had behavior problems. Most parents (83.3%) were reluctant to consider the option of special education.ConclusionSlow learners struggle to cope up with the academic demands of the regular classroom. They need to be identified at an early age and their parents counseled to understand their academic abilities.

Anxiety levels in mothers of children with specific learning disability

BACKGROUND Parents of children with specific learning disability (SpLD) undergo stress in coping with their childs condition. AIM To measure the levels of anxiety and find out the cause of anxiety in mothers of children with SpLD at time of diagnosis. SETTINGS AND DESIGN Prospective rating-scale and interview-based study conducted in our clinic. MATERIALS AND METHODS One hundred mothers of children (70 boys, 30 girls) with SpLD were interviewed using the Hamilton anxiety rating scale (HAM-A) and a semi-structured questionnaire. Detailed clinical and demographic data of mothers were noted. STATISTICAL ANALYSIS Chi-square test or unpaired students t-test was applied wherever applicable. RESULTS The mean age of mothers was 40.14 years (+/-SD 4.94, range 25.07-54.0), 73% belonged to upper or upper middle socioeconomic strata of society, 67% were graduates or postgraduates, 58% were full-time home-makers, and 33% lived in joint families. Levels of anxiety were absent in 24%, mild in 75%, and moderate in 1% of mothers. Their mean total anxiety score was 5.65 (+/-SD 4.75, range 0-21), mean psychic anxiety score was 3.92 (+/-SD 3.11, range 0-13), and mean somatic anxiety score was 1.76 (+/-SD 2.05, range 0-10). Their common worries were related to childs poor school performance (95%), childs future (90%), childs behavior (51%), and visits to our clinic (31%). CONCLUSION Most mothers of children with SpLD have already developed mild anxiety levels by the time this hidden disability is diagnosed. These anxieties should be addressed by counseling to ensure optimum rehabilitation of these children.

Prognostic clinical variables in childhood tuberculous meningitis: An experience from Mumbai, India

BACKGROUND In India, tuberculous meningitis (TBM) is still a major cause of neurological disabilities and death. AIM To identify the clinical variables which predict the outcome in childhood TBM. SETTING Tertiary teaching hospital. DESIGN Prospective observational study. MATERIALS AND METHODS Thirty-six clinical variables were analyzed in 123 consecutive children with TBM admitted between May 2000 and August 2003. The outcome was assessed in terms of survival or death. Survival meant that the patient was discharged from hospital having made a complete recovery, or with disability. RESULTS Twenty-five (20%) children recovered completely, 70 (57%) survived with disability, and 28 (23%) died. Employing univariate analysis nine variables correlated with survival with disability outcome: presence of tonic motor posturing, cranial nerve palsy, focal neurological deficit, hypertonia, moderate to severe hydrocephalus, cerebral infarction on cranial CT, and requiring shunt surgery, and absence of extracranial tuberculosis and no antituberculous-related hepatotoxicity; two variables correlated with fatal outcome: presence of deep coma (Glasgow coma scale score P = 0.012, d.f. = 1, OR 0.12, 95% CI 0.02-0.62) correlated with survival with disability outcome, and presence of deep coma (P = 0.030, d.f. = 1, OR 0.35, 95% CI 0.14-0.90) with fatal outcome. CONCLUSION In children with TBM, the presence of hypertonia at admission is an independent predictor of neurological sequelae in survivors, and deep coma is an independent predictor of mortality.

Health-related quality of life of children with newly diagnosed specific learning disability.

The objective of this study was to measure health-related quality of life (HRQL) of children with newly diagnosed specific learning disability (SpLD) using the Child Health Questionnaire-Parent Form 50. We detected clinically significant deficits (effect size > or = -0.5) in 9 out of 12 domains: limitations in family activities, emotional impact on parents, social limitations as a result of emotional-behavioral problems, time impact on parents, general behavior, physical functioning, social limitations as a result of physical health, general health perceptions and mental health; and in both summary scores (psychosocial > physical). Multivariate analysis revealed having > or = 1 non-academic problem(s) (p < 0.0001), attention-deficit hyperactivity disorder (p = 0.005) or first-born status (p = 0.009) predicted a poor psychosocial summary score; and having > or =1 non-academic problem(s) (p = 0.006) or first-born status (p = 0.035) predicted a poor physical summary score. HRQL is significantly compromised in children having newly diagnosed SpLD.

Febrile seizures: a review for family physicians.

Febrile seizures are the most common cause of convulsions in children. Most are simple in nature, although those with focal onset, prolonged duration ((3)15 min) or those that recur within 24 h or within the same febrile illness are considered complex. Diagnosis of this condition is essentially clinical and based on its description provided by parents. Its pathophysiology remains unclear, but genetics plays a major role in conferring susceptibility. Although most febrile seizures are benign and associated with minor viral illnesses, it is critical that the child be evaluated immediately to reduce parental anxiety and to identify the cause of the fever. It is essential to exclude underlying pyogenic meningitis, either clinically or, if any doubt remains, by lumbar puncture. The risk of pyogenic meningitis is as low (< 1.3%) as the risk in a febrile child without seizures. After an initial febrile seizure (simple or complex), 3-12% of children develop epilepsy by adolescence. However, the risk of developing epilepsy after an initial simple febrile seizure is low (1.5-2.4%). Since the vast majority of children have a normal long-term outcome, antiepileptic medication is not recommended to prevent recurrence of febrile seizures. Oral diazepam or clobazam, given only when fever is present, is an effective means of reducing the risk of recurrence. The family physician can play an important role in counseling the parents that most febrile seizures are brief, do not require any specific treatment or extensive work-up, the probability of frequent or possibly threatening recurrences is low and the long-term prognosis is excellent.