Vishwanath D. Patil

ENC training reduces perinatal mortality in Karnataka, India

Objective: To evaluate the effect of World Health Organization Essential Newborn Care course and the American Academy of Pediatrics Neonatal Resuscitation Program training on perinatal mortality in rural India. Methods: This study was part of a multi-country prospective, community-based cluster randomized controlled trial. Birth, 7-day and 28-day neonatal outcomes for all women with pregnancies greater than 28 weeks in the 26 study communities in Karnataka, India were included. Mortality rates pre- and post-Essential Newborn Care training were collected prospectively and then communities randomized to either receive neonatal resuscitation or refresher newborn care training in the control clusters. Results: Consent was obtained on 99% of the 25,096 births. Perinatal mortality for infants ≥500 g decreased from 52 to 36/1000 after newborn care training (RR 0.7; 95% CI 0.5, 0.9); stillbirth decreased from 23 to 14/1000 (RR 0.62; 95% CI 0.46, 0.83) and early neonatal mortality decreased from 29 to 22/1000 (RR 0.74; 95% CI 0.53, 1.03). Mortality was not reduced further with resuscitation training. Conclusions: Using a pre–post design, World Health Organization Essential Newborn Care community birth attendant training resulted in a significant reduction in perinatal mortality. In low-resource settings, the newborn care training package appears to be an effective intervention to decrease perinatal mortality.

A phase III, randomized controlled study to assess the safety and immunogenicity of a semi-synthetic diphtheria, tetanus and whole-cell pertussis vaccine in Indian infants

BACKGROUND Reactions to DTwP vaccine are well known and are a matter of great concern, much for the development of next generation combination vaccines. To avoid such reactions which occur from foreign compounds, WHO suggested manufacture of DTwP vaccine using semi-synthetic medium. The phase III trial reported here was conducted to assess the immunogenicity, tolerability and safety of a new DTwP vaccine manufactured using semi-synthetic medium for both tetanus and diphtheria toxoids in comparison with the routinely manufactured DTwP vaccine. METHODS In all, 331 infants aged 6-8 weeks were enrolled, out of which 308 completed the study. The vaccination was done at 6-10-14 weeks following EPI/WHO recommended immunization schedule. Blood samples were collected prior to the administration of first dose and one month after the third dose. RESULTS Postvaccination, geometric mean titres for each component did not differ significantly amongst the two study groups. Though, the immunogenicity results were comparable between the two vaccines, the incidence of adverse events was comparatively low in semi-synthetic vaccine as against the routine vaccine group for all the three doses. CONCLUSIONS The semi-synthetic DTwP vaccine was immunogenic and showed a significant lower incidence of local adverse events in comparison to the routine vaccine. This vaccine is now being used in the routine vaccination programme both as a triple antigen (DTwP alone) as well as a combination with Hepatitis B and/or Haemophilus influenzae type b vaccine.

Intact choledochal cyst with spontaneous common hepatic duct perforation: a spectrum of congenital biliary canal defects?

p JP A 3-month-old girl admitted for lower respiratory infection developed constipation and abdominal distension 3 days later. On examination, she had mild abdominal distension with absent bowel sounds. Abdominal sonography showed a normal biliary tract and pancreas. Computed tomography of abdomen revealed minimal localized fluid collection in the right upper quadrant. Abdominal paracentesis done 24 hours later revealed bile-stained ascitic fluid. Exploratory laparotomy on the same day revealed intact cystic dilation of common bile duct (type 1). Operative cholangiography revealed leakage of contrast from the distal common hepatic duct FIGURE 2. Excised intact choledochal cyst with gallbladder.

Migratory polyarthritis as a paraneoplastic syndrome in childhood leukemia

We write with reference to the recent article on arthritic presentation of childhood malignancy by Suri and colleagues, published in the journal [1]. We had recently come across a case of a 10-year-old child referred to us for evaluation of acute arthritis. The child had a 15-day history of joint pains, and continuous-type, mild-grade fever. Right-sided hip was the first joint to get involved in the form of stiffness, pain, and swelling, which, however, subsided spontaneously after 4 days, only to reappear in the ankle joint of the same limb. Left knee and ankle joint arthritis developed over next 8–10 days. There was no involvement of small joints, axial joints, and joints of upper limb. At no point of time the child had more than two joints involvement. The child was previously healthy. There was no history of trauma. He had no history of sore throat, skin rash, or bowel disturbance. There was no history of myalgia, night sweats, loss of appetite, or recent significant weight loss. The patient was treated by the referring physician, initially with aspirin, and later, with naproxen (25 mg/kg/day), and two doses of intravenous methyl prednisolone (30 mg/kg/dose) without relief. Blood investigations before the initiation of therapy were reported as normal. The child had no pallor, lymphadenopathy, organomegaly, or bony tenderness. Examination of eyes was normal. Laboratory investigations done in our center revealed hemoglobin 10.4 g/dL, leukocytes 9 9 10/L, and platelets 240 9 10/L. Peripheral blood smear was normocytic and normochromic, with no abnormal cell forms. X-ray of affected joints showed no radiological abnormality. Hepatic and renal function tests were normal. ASO-titer and C-reactive protein levels were normal. Rheumatoid factor, antinuclear antibody, and hepatitis-B serological tests were negative. Bone-marrow aspiration done later confirmed the diagnosis of acute lymphoblastic leukemia (subtype L2). Arthritic presentation of acute leukemia in children, though rare, is an established entity [1, 2]. Features suggesting a diagnosis of malignancy include a history of night pain, non-articular bony pain, anemia, and leukopenia [2]. Similar to the cases reported by Suri et al., our patient also had an arthritic presentation with normal blood counts. However, the joint pain in our case was asymmetric and migratory type involving the large joints, which makes our case unusual and interesting. The classical fleeting arthritis affecting multiple, weight-bearing joints made us to consider rheumatic fever and reactive arthritis as alternate diagnoses. Migratory polyarthritis has been previously described as a part of paraneoplastic syndrome in adults [3]. Our case also fulfilled the criteria for paraneoplastic syndrome: presentation during the course of, or preceding the diagnosis of malignancy, absence of evidence of direct tumor invasion, and symptomatic improvement with treatment of the underlining neoplasm. The learning objective of this report is acute-onset migratory polyarthritis can be a presenting feature of underlying hematopoietic malignancy in children.