Evidence of hepatitis A virus infection in the patients with acute encephalitis syndrome in Gorakhpur region, North India

The etiological agent remained unidentified in a large number of patients hospitalized for acute encephalitis syndrome (AES) in 2008-2009 in Uttar Pradesh and Bihar, north India. All patients were found to present with fever and altered sensorium, while 28%, 19% and 13% showed hepatomegaly, splenomegaly and meningeal signs, respectively. Involvement mostly of children with abnormal hepatic features prompted us to undertake an exploratory study on viral hepatitis A to determine its association, if any, with hepatic derangements. AES patients (n = 2515) and healthy children (n = 167) were investigated for the presence of serum anti-hepatitis A virus (anti-HAV) IgM and anti-Japanese encephalitis (anti-JE) virus IgM by ELISA. Cerebrospinal fluids (CSFs, n = 595) and rectal swabs (n = 182) were examined for anti-HAV IgM and/or HAV RNA. Anti-HAV IgM was detected in the sera of 14.6% patients as against 6.6% of healthy children (p = 0.0042). Anti-JE virus IgM positivity was Keywords: acute encephalitis syndrome; cerebrospinal fluid; hepatitis A virus; anti-HAV IgM; non-Japanese encephalitis.

WHO/UNICEF recommended therapeutic food versus home based therapeutic food in the management of severe acute malnutrition: A randomized controlled trial

Malnutrition is a major public health problem especially in the developing countries. The objective of the study was to compare WHO/UNICEF recommended therapeutic food with home based therapeutic food in the management of severe acute malnutrition. It was a randomized controlled trial at tertiary care level hospital with nutritional rehabilitation centre. Children (6 month to 5 years) having severe acute malnutrition were included in the study. Group A (n=74 children) was given WHO recommended therapeutic food and group B (n=75 children) was given home based therapeutic food. The mean rate of weight gain, gain in height and increase in mid-upper arm circumference were significantly higher (p<0.05) in the group received home based therapeutic food. Mean duration to achieve target weight was 21.44±3.33 days in group A and 16.28±2.11 days in group B (p<o.ooo1). Group B children had higher rate of increase in urinary creatinine (p<0.0001). Affordability (p<0.0001), Feasibility (p=0.027) and Average frequency of feeding per day (p<0.0001) was found significantly higher in group B. Difficulty in making therapeutic food was significantly low in group B (p<0.05). Both kinds of therapeutic food were effective for the management of severe acute malnutrition, but the home based therapeutic food was found to be more effective. This could be explained by better acceptability in terms of better palatability, more affordability, increased frequency of feeding, and having less difficulty in making.

Management of children with severe acute malnutrition: experience of Nutrition Rehabilitation Centers in Uttar Pradesh, India

OBJECTIVE

To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in Nutrition Rehabilitation Centers (NRC).

DESIGN

Review of data.

SETTING

12 NRCs in Uttar Pradesh, India.

PARTICIPANTS

Children admitted to NRCs (Jan 1, 2010 - Dec 31, 2011).

INTERVENTION

Detection and treatment of SAM with locally-adapted protocols.

OUTCOMES

Survival, default, discharge, and recovery rates.

RESULTS

54.6% of the total 1,229 children admitted were boys, 81.6% were in the age group 6-23 months old, 86% belonged to scheduled tribes, scheduled castes, or other backward castes, and 42% had edema or medical complications. Of the 1,181 program exits, 14 (1.2%) children died, 657 (47.2%) children defaulted, and 610 (51.7%) children were discharged The average (SD) weight gain was 12.1 (7.3)g/kg body weight/day and the average (SD) length of stay was 13.2 (5.6) days. 206 (46.8%) children were discharged after recovery (weight gain >15%) while 324 (53.2%) were discharged, non-recovered (weight gain <15%).

CONCLUSIONS

NRCs provide life-saving care for children with SAM; however, the protocols and therapeutic foods currently used need to be improved to ensure the full recovery of all children admitted.

Obstetric behavior and pregnancy outcome in overweight and obese women: maternal and fetal complications and risks in relation to maternal overweight and obesity

OBJECTIVE

To perform analyses of maternal and fetal complications in overweight and obese women.

METHODS

Eighty-seven women with singleton pregnancies with BMI > 25-29.9 kg/m(2) and 83 women with singleton pregnancies with BMI > 30 kg/m(2) were studied for maternal and fetal complications at Nehru Hospital, B.R.D. Medical College, Gorakhpur during June 2007-October 2008. Forty-five women with BMI 20-24.9 kg/m(2) were selected to serve as control.

RESULTS

Compared with women with normal BMI, the outcomes which were more common in overweight and obese women were gestation hypertension (p < 0.05); pre-eclampsia (p < 0.001); preterm delivery (p < 0.05); induction of labor (p < 0.05); instrumental vaginal delivery (p > 0.05); cesarean section (p < 0.01); increased operative time (p < 0.01); still births (p < 0.05); early neonatal deaths (p < 0.05); Apgar score < 7 at 5 min (p < 0.05); and admission to NICU (p < 0.001). No significant differences were noted among groups regarding hypoglycemia hyperbilirubinemia and respiratory distress.

CONCLUSION

Overweight and obesity are definite risk factors for adverse pregnancy outcomes. This may be due to altered metabolic state in obesity.

Changing clinico-laboratory profile of encephalitis patients in the eastern Uttar Pradesh region of India

A cross-sectional study was done on 100 consecutive paediatric patients presenting with acute encephalitis syndrome. The clinico-laboratory features of all patients were recorded in a prestructured performa. Cerebrospinal fluid and serum samples were tested for: Japanese encephalitis (JE) virus; Chandipura virus; coxsackie virus; dengue virus; enterovirus 76; and West Nile virus. Twenty-two (22.0%) patients were confirmed JE cases and 17% had parasitic or bacteriological aetiology. The remaining 61 cases (61.0%) in which no viral aetiological agent was found were grouped as non-JE cases. Peripheral vascular failure, splenomegaly and hypotonia were distinguishing clinical features found in the non-JE patients. A high mortality of 26.5% was seen in patients with confirmed or presumptive viral encephalitis (22/83). A fatal outcome was independently associated with peripheral vascular failure and pallor at the time of admission. Early recognition of these signs may help clinicians to manage these cases.

Concurrent infection of Japanese encephalitis and mixed plasmodium infection

Japanese encephalitis (JE) and malaria would coexist in the areas where both illnesses are endemic with overlapping clinical pictures, especially in a case of febrile encephalopathy with hepatosplenomegaly. However, there are no published data till date showing concurrent infection of these two agents despite both diseases being coendemic in many areas. We report a case of concurrent infection of JE and mixed plasmodium infection, where the case, initially diagnosed as cerebral malaria did not improve on antimalarials and alternative diagnosis of JEV encephalitis was thought which was confirmed by a serological test. To the best of our knowledge, this is the first case report of concurrent Japanese encephalitis with mixed plasmodium infection. We report a case of 3-year-old male child, who presented with febrile encephalopathy with hepatosplenomegaly. Based on a rapid diagnostic test and peripheral smear examination, a diagnosis of mixed P.Vivax and P.falciparum infection was made and the patient was treated with quinine and doxycycline. However, besides giving antimalarials the patient did not improve and an alternative diagnosis of JE was considered as the patient was from the endemic zone of Japanese encephalitis. Cerebrospinal fluid (CSF) of the patient was sent for a virological study which came out to be positive for JE IgM in CSF, which is confirmatory of JE infection. In a patient with febrile encephalopathy with hepatosplenomegaly especially in areas coendemic for JE and malaria, the possibility of mixed infection should be kept in mind.

Enteroviruses in patients with acute encephalitis, uttar pradesh, India

An outbreak of viral encephalitis occurred in northern India in 2006. Attempts to identify an etiologic agent in cerebrospinal fluid by using reverse transcription-PCR showed positivity to enterovirus (EV) in 66 (21.6%) of 306 patients. Sequencing and phylogenetic analyses of PCR products from 59 (89.3%) of 66 specimens showed similarity with EV-89 and EV-76 sequences.

New species of Phaeoramularia, Pseudocercospora and Stenella from Western Ghats of India

Four new species of the hyphomycete genera Phaeoramularia viz. Ph. caesalpinae, Pseudocercospora viz., Ps. tiliacearum, Stenella, viz. S. argyreiae and S. grewiae occurring on Caesalpinia bonducella Fleming (Caesalpiniaceae), Grewia sp. (Tiliaceae), Argyrea sp. Lour (Convolvulaceae) and Grewia sp. L. (Tiliaceae), respectively are described and illustrated here. All these fungi were collected from Western Ghats of India.

Detection and prevention of childhood disability with the help of Anganwadi workers

OBJECTIVES

To evaluate the role of Anganwadi Workers (AWW) for detection and prevention of disability in children below 6 years of age.

DESIGN

Cross sectional and longitudinal follow up.

SETTING

Ten Anganwadi Centers in ICDS Urban Project.

METHODS

Trained AWWs identified disabilities and instituted preventive measures like immunization and supplementary nutrition. Simultaneous independent verification by pediatricians. Repeat survey after 6 mo of follow-up.

RESULTS

Amongst the 1545 children, AWW identified disability in 126 subjects which were verified in 118 cases by pediatricians. The disability rate was 7638 per 100,000 population. Visual, mental, orthopedic, speech and hearing disabilities rates were 4790, 2654, 583, 518 and 453 per 100,000 population, respectively. In the repeat survey, 35 of the 74 children with visual disability (mostly xerophthalmia), 4 of the 9 with orthopedic disability and 3 of the 7 with hearing disability could be managed satisfactorily.

CONCLUSIONS

AWW can help in early detection and appropriate management of incipient and preventable childhood disabilities.

Surveillance of drug induced diseases in children

A hospital based prospective study on drug induced diseases (DID) in children below 14 years of age was done for a duration of two years. A total number of 20,310 patients were examined in pediatric department during this period, out of which 204 (1.004%) patients were diagnosed as DID. Children with severe reactions were admitted in pediatric ward for in hospital intensive surveillance. The male:female ratio in DID was 1.2:1. DID were most common in neonates (24.51%). Erythmatous maculopapular rashes (67.12%) formed the most common pool of DID in neonates. Thrombophlebitis (41.56%) was most commonly seen in infants above 28 days of life, and in children up to 14 years of age. Out of 204 cases of DID, 9 (4.41%) died. Aplastic anemia was most morbid DID, as all the 7 patients of aplastic anemia died. Chloramphenicol was responsible for all the cases of aplastic anemia. Other two deaths were from erythma multiforme and C.C.F. The most commonly involved drugs, other substances and vaccines were baby powders, massage oils, ampicillin, co-trimoxazole, i.v. infusions (electrolytes and mannitol), DPT and measles vaccines.

Growth patterns in breastfed babies during first six months of life

Growth of exclusively breastfed 126 normal newborns in urban slums and those delivered at Nehru Hospital, Medical College, Gorakhpur were studied upto six months of age. The average weight of both boys and girls was almost equivalent to the 25th percentile of NCHS standard upto 3 months but fell below these standards thereafter. The average length in both boys and girls was between 25th and 50th percentile of NCHS data. The average head circumference in girls was between 25th and 50th percentile of NCHS data at all ages but in boys it was between 10th and 25th percentile at 4, 5 and 6 months of age. The average weight, length, head and chest circumference in both boys and girls were comparable to ICMR standards. The observations indicate that exclusive breastfeeding should be promoted for adequate growth of infants during first six months of life.

Breastfeeding and childhood cancer

Total duration of breastfeeding and of exclusive breastfeeding was studied and compared in 99 childhood cancer cases and 90 controls. The difference between the average duration of breastfeeding in cases and controls was significant (p < 0.05), but when average duration of exclusive breastfeeding was compared in cases and controls the difference was highly significant (p < 0.001). In lymphoma cases and controls the difference between the average duration of breastfeeding was moderately significant (p < 0.01). However, when average duration of exclusive breastfeeding was compared in lymphoma cases and controls the difference was highly significant (p < 0.001). When other cancer groups and controls were compared with respect to their total duration of breastfeeding and duration of exclusive breastfeeding the differences when insignificant (p > 0.05). Cases and controls were not different with respect to their age, sex, birth year, birth order, age and educational status of mothers, smoking of fathers and socioeconomic status. However, a positive family history of cancer was obtained in 4 (4%) of cases whereas in controls it was obtained in only 1 (1.1%).

Pregnancies in adolescents: fetal, neonatal and maternal outcome

We studied the perinatal morbidity and mortality among adolescent pregnancies in the semi-urban population of Gorakhpur. The number of eligible couples (females 15-44 yrs) were 24,000. Out of 430 adolescent married girls, 242 (56.3%) became pregnant during the study period. Nineteen (7.8%) of adolescent pregnancies were in the maternal age group less than 15 years and 110 (45.5%) and 113 (46.7%) pregnancies were in the age group 15-17 yrs and 17-19 yrs, respectively. The incidence of low birth weight babies was 67.3% of all live births. Infections during neonatal period, congenital anomalies and birth injuries were seen in 21.6, 8.6 and 13.1% newborns, respectively. Neonatal mortality rate was 136.2/1000 live births. Three adolescent mothers died during pregnancy or puerperium due to causes related to pregnancy. The incidence of LBW, neonatal and maternal morbidity and mortality associated with adolescent pregnancies were significantly higher.

JE virus encephalitis: 1988 epidemic at Gorakhpur

Gorakhpur region experienced the most serious outbreak of Japanese encephalitis (JE) in 1988 in which 875 children were admitted in the Department of Pediatrics, BRD Medical College, Gorakhpur. Children between 7-10 years age group constituted half (49.3%) of these cases, convulsions (83.8%), altered sensorium (78.2%), headache (68.8%) and hypertonia (77.0%) were the main presenting features. IgM against JE virus was demonstrated in 18/25 CSF and 27/53 sera collected from these children. Significant titres of HI antibodies against JE were present in 498/670 patients. Patients were managed symptomatically. Dexamethasone and dopamine were given to only 137 (15.7%) children admitted with shock and peripheral circulatory failure. Almost a third (31.8%) of the patients expired, 51.4% recovered completely and 10.7% recovered partially. Corticosteroids did not improve the outcome. Twenty four patients had recurrence of symptoms after excellent recovery from acute attack of whom two died and 5 developed neurological deficits.

Prevalence and abuse of psychoactive substances in children and adolescents

The present study has been carried out in the slum areas of Gorakhpur city, covering a population of 10,187 in the four colleges of Gorakhpur. Five hundred and eighty children and adolescents in urban slums, and 750 college students between 10-18 years were studied by means of a questionnaire card for detection of prevalence rate and various others co-relates of abuse of psychoactive substances. Overall, prevalence of abuse of psychoactive substances was 25% in slum areas, and 18% in college students. Abuse of tobacco was most frequent (50.3% & 72.5%) followed by that of alcohol (11.7% & 16.2%) in both the groups respectively. Cannabis was also used by some children (0.6%). More abusers were from Hindu families with low educational status and low family income. Surprisingly no one was found to be abusing tablets and street drugs.

Serogenetic variation in four caste populations of Haryana, India

The phenotypes and gene frequencies of 3 blood groups, 7 red-cell enzymes and a serum protein were studied in 4 caste population groups of Haryana, North India. The results indicate that the distribution of these blood markers is rather homogeneous in the 4 groups and generally resembles that observed in various populations from neighbouring North Indian states.

Prescription audit of under six children living in periurban areas

One hundred and seventy two children were prescribed, in 212 episodes of illness, antimicrobial agents (28.4%), followed by antidiarrheals (10.9%), nutritional products (9.4%), analgesics (7.5%) and steroids (6.8%). Ampicillin (22.7%) and cotrimoxazole (12.7%) were the most commonly prescribed antimicrobials. Tetracyclines, which are not indicated in children below 8 years, were used in 7.1% of total exposures of chemotherapeutic agents. Penicillin, a comparatively safe and useful drug, was used only in 4.5% exposures. Analgin and hydroxyquinolines were used frequently. Corticosteroids were used for simple ailments like diarrhea, fever and jaundice. ORS was used in only 13.9% episodes of diarrhea. Adverse drug reactions were noted in 30 (17.4%) cases and death in 6 (3.5%) cases. The average cost per prescription for neonates was Rs 32.43 and for a child was Rs 30.65. Weight of the children was not taken prior to prescribing drugs. There is need for prescription audit as there is high consumption rate of drugs, with overuse of antimicrobial and nutritional products, and misuse of steroids.