Consensus Statement of the IAP - Neurodevelopmental Chapter On Neurodevelopmental Disorders Habilitation Process: Strategic Plan for Prevention, Early Detection and Early Intervention

JUSTIFICATION

Neurodevelopmental disorders, as per DSM-V, are described as a group of conditions with onset in the development period of childhood. There is a need to distinguish the process of habilitation and rehabilitation, especially in a developing country like India, and define the roles of all stakeholders to reduce the burden of neurodevelopmental disorders.

PROCESS

Subject experts and members of Indian Academy of Pediatrics (IAP) Chapter of Neurodevelopmental Pediatrics, who reviewed the literature on the topic, developed key questions and prepared the first draft on guidelines. The guidelines were then discussed by the whole group through online meetings, and the contentious issues were discussed until a general consensus was arrived at. Following this, the final guidelines were drafted by the writing group and approved by all contributors.

OBJECTIVES

These guidelines aim to provide practical clinical guidelines for pediatricians on the prevention, early diagnosis and management of neurodevelopmental disorders (NDDs) in the Indian settings. It also defines the roles of developmental pediatricians and development nurse counselor.

STATEMENT

There is a need for nationwide studies with representative sampling on epidemiology of babies with early NDD in the first 1000 days in India. Specific learning disability (SLD) has been documented as the most common NDD after 6 years in India, and special efforts should be made to establish the epidemiology of infants and toddlers at risk for SLD, where ever measures are available. Preconception counseling as part of focusing on first 1000 days; Promoting efforts to organize systematic training programs in Newborn Resuscitation Program (NRP); Lactation management; Developmental follow-up and Early stimulation for SNCU/ NICU graduates; Risk stratification of NICU graduates, Newborn Screening; Counseling parents; Screening for developmental delay by trained professionals using simple validated Indian screening tools at 4, 8, 12, 18 and 24 months; Holistic assessment of 10 NDDs at child developmental clinics (CDCs) / district early intervention centre (DEICs) by multidisciplinary team members; Confirmation of diagnosis by developmental pediatrician/developmental neurologist/child psychiatrist using clinical/diagnostic tools; Providing parent guided low intensity multimodal therapies before 3 years age as a center-based or home-based or community-based rehabilitation; Developmental pediatrician to seek guidance of pediatric neurologist, geneticist, child psychiatrist, physiatrist, and other specialists, when necessary; and Need to promote ongoing academic programs in clinical child development for capacity building of community based therapies, are the chief recommendations.

Aqueously altered igneous rocks sampled on the floor of Jezero crater, Mars

The Perseverance rover landed in Jezero crater, Mars, to investigate ancient lake and river deposits. We report observations of the crater floor, below the crater's sedimentary delta, finding the floor consists of igneous rocks altered by water. The lowest exposed unit, informally named Séítah, is a coarsely crystalline olivine-rich rock, which accumulated at the base of a magma body. Fe-Mg carbonates along grain boundaries indicate reactions with CO₂-rich water, under water-poor conditions. Overlying Séítah is a unit informally named Máaz, which we interpret as lava flows or the chemical complement to Séítah in a layered igneous body. Voids in these rocks contain sulfates and perchlorates, likely introduced by later near-surface brine evaporation. Core samples of these rocks were stored aboard Perseverance for potential return to Earth.

Fluorescent Tracers for In Vivo Imaging of Lymphatic Targets

The lymphatic system continues to gain importance in a range of conditions, and therefore, imaging of lymphatic vessels is becoming more widespread for research, diagnosis, and treatment. Fluorescent lymphatic imaging offers advantages over other methods in that it is affordable, has higher resolution, and does not require radiation exposure. However, because the lymphatic system is a one-way drainage system, the successful delivery of fluorescent tracers to lymphatic vessels represents a unique challenge. Each fluorescent tracer used for lymphatic imaging has distinct characteristics, including size, shape, charge, weight, conjugates, excitation/emission wavelength, stability, and quantum yield. These characteristics in combination with the properties of the target tissue affect the uptake of the dye into lymphatic vessels and the fluorescence quality. Here, we review the characteristics of visible wavelength and near-infrared fluorescent tracers used for in vivo lymphatic imaging and describe the various techniques used to specifically target them to lymphatic vessels for high-quality lymphatic imaging in both clinical and pre-clinical applications. We also discuss potential areas of future research to improve the lymphatic fluorescent tracer design.

The Effects of Terrain Properties Upon the Small Crater Population Distribution at Giordano Bruno: Implications for Lunar Chronology

The distribution of impact craters on the ejecta of Giordano Bruno, a recent (<10 Ma) 22-km diameter crater within the lunar highlands, exhibits substantial variations. We surveyed craters D ≥ 10 m across a 1,323 km² area of Giordano Bruno's ejecta and compared the distribution of craters with variations in thermophysical properties derived from the Lunar Reconnaissance Orbiter Diviner instrument. We used Diviner-derived rock abundance and nighttime regolith temperatures along with thermal model-predicted surface temperatures for a diversity of terrains to identify and isolate areas of the ejecta based on thermophysical properties such as bulk density and thermal conductivity. We found that thermophysical properties of the ejecta vary considerably both laterally and vertically, and consistently differ from typical regolith, indicating the presence of higher thermal inertia materials. Crater-size frequencies are significantly lower in areas with terrain properties exhibiting higher: rock abundance, nighttime temperatures, and/or modeled thermal inertia. This discrepancy in crater distribution increases for craters smaller than ∼25 m. These thermophysical variations indicate changes in the mechanical properties of the target materials. We suggest that these variations-specifically, terrain-dependent crater scaling variations and impactor-scale heterogeneities in material properties such as the presence or absence of large boulders-may influence crater diameters or inhibit crater production altogether in Giordano Bruno's ejecta; furthermore, these factors are size-dependent.

Depletion of foxp3(+) T cells abrogates tolerance of skin and heart allografts in murine mixed chimeras without the loss of mixed chimerism

The relative contribution of central and peripheral mechanisms to the generation and maintenance of allograft tolerance is of considerable interest. Here, we present new evidence that regulatory T cells (Foxp3(+) ) maintain skin and heart allograft tolerance in mixed hematopoietic chimeric mice. Transient depletion of both donor- and recipient-derived Foxp3(+) cells was necessary and sufficient to induce decisive rejection of long-accepted skin and heart allografts. In contrast, stable hematopoietic chimerism remained, and there was no detectable induction of donor-specific reactivity to hematopoietic cells. Foxp3(+) cell depletion did not result in the rejection of skin grafts of only MHC-disparate donors (B6.C-H2(d) /bByJ), indicating that MHC antigens were not the target in the graft. We conclude that two different mechanisms of tolerance are present in mixed chimeras. Hematopoietic chimerism, resistant to Foxp3(+) depletion, is probably due to deletional tolerance to MHC antigens, as supported by previous studies. In contrast, regulatory tolerance mechanisms involving Foxp3(+) cells are required to control reactivity against non-MHC antigens not present on hematopoietic lineages.

Development and normative validation of Developmental Assessment Tool for Anganwadis for 3- to 4-year-old children (DATA-II)

OBJECTIVE

To develop, standardize, and validate a developmental scale for children, 3-4 years old, attending Anganwadis (Integrated Child Development Scheme) in India, as a follow-up assessment, using a normative approach.

STUDY DESIGN AND SETTING

After the development of the 12-item Developmental Assessment Tool for Anganwadis (DATA-II), its internal consistency as well as face, content, and construct validities were studied in 100 children in Anganwadis and were found to be appropriate. A total of 385 children with a mean (standard deviation) age of 43.05 (5.02) months from randomly selected 36 Anganwadis were recruited for its standardization. Raw scores were converted to standardized T scores. Scoring pattern for domains and aggregate developmental scores were formulated.

RESULTS

Except for four items in the original scale, all the items were endorsed by parents suggesting a good content validity, and Kuder-Richardson Formula 20 coefficient of 0.80 suggested a high internal consistency. Factor analysis replicated the six-factor structure explaining 76.5% of variance. An aggregated developmental score based on the standardized T scores demonstrated that a DATA-II score between 29 and 33 suggested "at risk" for developing developmental delays. A score of 28 or less suggested already delayed milestones. A score of 19-28 suggested a "mild delay," 8-18 suggested a "moderate delay," and 7 or less suggested a "severe delay" in development.

CONCLUSION

The DATA-II is a measure for use in Anganwadis for identifying children at risk or with developmental delays during the first follow-up assessment, in India, for appropriate referrals and interventions.

Development and validation of language evaluation scale Trivandrum for children aged 0-3 years--LEST (0-3)

OBJECTIVE

To develop and validate a simple screening tool which can be used in the Community to identify delay in language development among children of 0-3 years of age.

METHODS

The normal range for the 33 items of Language Evaluation Scale Trivandrum for 0-3years LEST(0-3) were carefully selected from various existing language development charts and scales, by experts keeping in mind the face validity and content validity. The criterion validity was assessed using a community sample of 643 children of 0 to 3 years of age, including 340 (52.9%) boys. LEST (0-3) was validated against Receptive Expressive Energent Language Scale, for screening delay in language development among children of 0-3 years.

RESULTS

When one item delay was taken as LEST delay (test positive), the sensitivity and specificity of LEST(0-3), was found to be 95.85% and 77.5%, respectively with a negative predictive value of 99.8% and LR (negative) of 0.05.When two item delay was taken as LEST delay(test positive), the sensitivity and specificity of LEST(0-3), was found to be 66.7% and 94.8% respectively with a negative predictive value of 98.7% and LR (negative) of 0.35. The test-retest and inter-rater reliability were good and acceptable (Inter-class correlation of 0.69 for test-retest and 0.94 for inter-rater).

CONCLUSIONS

LEST (0-3) is a simple, reliable and valid screening tool for use in the community to identify children between 0-3 years with delay in language development, enabling early intervention practices.

A novel pathway of chronic allograft rejection mediated by NK cells and alloantibody

Chronic allograft vasculopathy (CAV) in murine heart allografts can be elicited by adoptive transfer of donor specific antibody (DSA) to class I MHC antigens and is independent of complement. Here we address the mechanism by which DSA causes CAV. B6.RAG1(-/-) or B6.RAG1(-/-)C3(-/-) (H-2(b)) mice received B10.BR (H-2(k)) heart allografts and repeated doses of IgG2a, IgG1 or F(ab')(2) fragments of IgG2a DSA (anti-H-2(k)). Intact DSA regularly elicited markedly stenotic CAV in recipients over 28 days. In contrast, depletion of NK cells with anti-NK1.1 reduced significantly DSA-induced CAV, as judged morphometrically. Recipients genetically deficient in mature NK cells (γ-chain knock out) also showed decreased severity of DSA-induced CAV. Direct NK reactivity to the graft was not necessary. F(ab')(2) DSA fragments, even at doses twofold higher than intact DSA, were inactive. Graft microvascular endothelial cells responded to DSA in vivo by increased expression of phospho-extracellular signal-regulated kinase (pERK), a response not elicited by F(ab')(2) DSA. We conclude that antibody mediates CAV through NK cells, by an Fc dependent manner. This new pathway adds to the possible mechanisms of chronic rejection and may relate to the recently described C4d-negative chronic antibody-mediated rejection in humans.

A panchayat level primary-care approach for adolescent services

OBJECTIVE

To develop a model for providing community adolescent care services in the primary care setting

METHODS

Need assessment was done among adolescents and perceived problems of adolescents were studied using qualitative and quantitative methods. Based on the results of these studies, a Family Life Education (FLE) module was prepared. Awareness programs were organized for all stakeholders in the community on adolescent issues. All anganwadi workers in the panchayat were trained to take interactive sessions for all the adolescents in the panchayat using the FLE module. Ward based Teen Clubs were formed in all the 13 wards of the Panchayat separately for boys and girls and FLE classes were given to them through anganwadi workers. An Adolescent Clinic was set up to provide necessary medical and counseling facilities. Adolescent Health Card was distributed to all Teen Club members and those who attended the adolescent clinics.

RESULTS

The present approach stresses the need and feasibility of adolescent-centered, community-based interventions. The authors' experience showed that before starting any adolescent program, community awareness generation about the need and content of the program is very important for its success. The experience of this model has made it possible to up-scale the program to seven districts of southern Kerala as a service model.

CONCLUSIONS

The experiences of the program gave a realistic picture of the needs and problems of adolescents and a simple feasible model for providing services to adolescents in the primary care setting that can be easily replicated in other parts of India.

Priority mental health disorders of children and adolescents in primary-care pediatric setting in India 1: developing a child and adolescent mental health policy, program, and service model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.

School based adolescent care services: a district model

OBJECTIVE

To study the perceived problems of higher secondary school students in a district and to document the effect of a family life and life skill education package.

METHODS

A survey was conducted among 11501 adolescents belonging to 103 higher secondary schools in Thiruvananthapuram district, using Teenage Screening Questionnaire-Trivandrum (TSQ-T). Family life and life skill education package was given to class XI students and post intervention evaluation of improvement in knowledge level was assessed after 6 months by a structured pre-tested self-administered questionnaire.

RESULTS

61.2% adolescents reported scholastic problem, 22.1% family related problems, 31.9% personal problems and 15.2% adjustment problems, with boys reporting higher percentage. 65.8% reported body image related problems, 26.4% had dental, 21.3% ENT and 16.2% had dermatological complaints. Among girls 50.2% reported menstrual problems. 506 adolescents volunteered for medical check-up and 1247 for detailed psychological assessment. Family life and life skill education package showed consistent improvement in knowledge even after a gap of 6 months.

CONCLUSIONS

The study results showed that a school based adolescent care service programme is effective and feasible.

Priority mental health disorders of children and adolescents in primary-care pediatric settings in India 3: psychotherapy and other non-pharmacological interventions

The pediatrician is a primary column of support for children and adolescents with a myriad of mental health problems in low-mental health care resource countries like India. While majority of mental health consultations happen in primary-care, and only 10% are referred successfully for specialised help, there is a clear role for pediatrician psychotherapists in primary care. The primary-care pediatricians should be aware of the indications for psychotherapy, the various approaches that could be used in primary-care settings, the structure and the process of the psychotherapeutic technique involved, the suggested specific techniques for the Priority Mental Health Disorders and the evidence available to support their use as well as the developmental modifications that are required based on the cognitive development of the child or adolescent.

Adolescent health care in India: progressive, regressive or at the cross-roads?

India has a sizeable adolescent population. Adolescents constitute a vulnerable population for both mental and physical illnesses, and yet their health-care needs and delivery systems are neither well defined nor developed. Many of the mental, reproductive and nutritional health needs of this population are required to be addressed and can be addressed in the primary-care pediatric setting itself if the current system of health-care can be re-organized. This restructuring will be more effective for this population if adolescent friendly approaches, public-private partnership and policy as well as sectoral linkage between the NRHM and other national programs are achieved. The health program for this age group should have promotive and preventive as well as remedial and curative components. Also, improving the availability of trained personnel in these areas of health, culturally sensitive evidence based approaches and capacity building in the primary-care approach is essential to ensure the viability of adolescent health-care in this country.

Effectiveness of a reproductive sexual health education package among school going adolescents

OBJECTIVE

To assess the effectiveness of a school based "Adolescent Reproductive Sexual Health Education (ARSHE) Package" in improving students' knowledge on reproductive sexual health matters.

METHODS

An ARSHE package originally developed at Child Development Centre, Kerala, modified and approved by ICMR taskforce group was administered in three urban schools (One boys only, one girls only and one co-education) and one co-education rural school at Thiruvananthapuram district, Kerala. The study sample consisted of 1,586 adolescents including 996 boys and 560 girls of class IX and XI. Pre and post intervention knowledge regarding reproductive sexual health matters was assessed using a self-administered questionnaire.

RESULTS

In the pre-intervention period, it was observed that majority of adolescents were poorly informed about reproductive sexual health matters, particularly about contraceptives. As compared to boys, girls had much poorer knowledge about prevention of pregnancy and after intervention; there was a statistically significant increase in the knowledge in both boys and girls. Among girls percentage of poor knowledge had reduced significantly from 64.1% to 8.3% and among boys from 37.7% to 3.5%. Similarly, increase in knowledge level was also observed in various other aspects of reproductive and sexual health including, STI, HIV/AIDS and perceptions about premarital sex.

CONCLUSIONS

The study results revealed the feasibility and effectiveness of school based reproductive and sexual health education intervention programs for adolescents.

Priority mental health disorders of children and adolescents in primary-care pediatric settings in India 2: diagnosis, pharmacological treatment and referral

The advent of pediatric psychopharmacology has enormously improved psychiatric care of children and adolescents. Nonetheless, our practice of diagnosis, treatment and referral in primary-care pediatric settings is not optimum as current evidence based knowledge is not regularly applied in the actual clinical circumstances. To help primary-care pediatricians minimise this in research-clinical practice, pharmacological treatment and referral in their clinical practice, they need to follow a two-tier diagnostic and multi axial treatment approach. The two-tier diagnostic approach of using a screening measure followed by confirmation of the screen positive cases with reference standard clinical criterion, improves the sensitivity and specificity. The multiaxial treatment has the advantage of offering a holistic approach to the intervention and improve prognosis from the interacting axes. The primary-care physician should be aware of the medications of choice for the Priority Mental Health Disorders and their drug interactions. Finally, referral of cases with atypical presentations, multiple comorbidities and poor response to the first-line of treatment needs referral to the next tier in the system.

Priority mental health disorders of children and adolescents in primary-care pediatric settings in India 4: training and capacity building

Training in the primary-care child and adolescent mental health should take into consideration the local milieu, national health care education and development. It should aim to improve the mental health knowledge, competency as well as develop professional relationships between various primary, secondary and tertiary-care mental health providers to enhance outcomes. The collaborative training between the various stakeholders in the Child and Adolescent Mental Health (CAMH) should be enhanced. Currently, the favoured methods, to augment the training for practicing Primary-care Physicians, like CME and short training programs with their specific goals, settings and methodology are well documented. However, to improve the skills in CAMH for medical trainees at undergraduate and postgraduate levels, restructuring of the curriculum is essential.

Comparison of a self-rated and a clinician-rated measure for identifying depression among adolescents in a primary-care setting

OBJECTIVE

To compare the diagnostic accuracy of a self-rated and a clinician rated measure of depression for primary care use in school setting by pediatricians.

METHODS

Two tools for screening depression were administered to early adolescents in three schools. These included the self-rated Beck Depression Inventory (BDI), pediatrician rated Children's Depression Rating Scale-Revised (CDRS-R), and ICD-10 clinical interview by a psychiatrist as reference standard. These tools were compared for their overall performance using Areas Under the Curve (AUC) of Receiver Operating Characteristic (ROC) curves. The optimal screening threshold score for both tools were identified from their sensitivity and specificity plotted for all threshold scores. For the optimal cut-off scores, the diagnostic accuracy parameters like sensitivity, specificity, predictive values, likelihood ratio and diagnostic odds ratio were calculated using contingency table.

RESULTS

The area under the curve for BDI was 0.67 and CDRS was 0.50 suggesting that BDI as a screening tool has better diagnostic accuracy. The optimal screening threshold score for BDI was 18 with a sensitivity of 63 and specificity of 70. For the CDRS-R cut-off score of 59, the sensitivity was 36 and specificity was 82 respectively. Using both tools concurrently improved the diagnostic accuracy.

CONCLUSIONS

Using the ROC characteristics and various validity indices, the authors showed that BDI has better sensitivity and CDRS-R a better specificity. It might be prudent to use both these instrument simultaneously to improve the identification of depression in primary care settings like school health clinic.

Psychopathology, traumatic life events, and coping skills among patients attending a primary-care adolescent clinic

OBJECTIVE

To compare the type of life events experienced and coping styles used by adolescents with and without psychopathology, attending a primary-care adolescent clinic.

METHODS

One hundred adolescents with and without psychopathology attending a drop-in adolescent clinic in a tertiary-care teaching hospital were recruited. Face-to-face interview used Child Behaviour Checklist, Life Event Scale, Coddington's life event scale, Impact of Event Scale and Modified Jalowiec coping scale as measures after getting written, informed consent from the primary care-giver and verbal assent from the adolescents. Bivariate and multivariate comparisons were done between the groups appropriately.

RESULTS

Adolescents with psychopathology had experienced more parental fights, increased arguments with parents, increased arguments between parents, serious illness requiring hospitalization of the adolescent. The intrusive symptoms of PTSD were noted more than avoidant symptoms among those adolescents with life events. Confrontative, emotive and optimistic coping styles were most often used in adolescent with psychopathology.

CONCLUSIONS

In India, adolescents with psychopathology attending a primary care clinic have significant life events and different coping styles. Therefore, adolescents with psychopathology in this setting should be screened for life events as well as dysfunctional coping styles and given appropriate intervention.

Attitude of parents and teachers towards adolescent reproductive and sexual health education

OBJECTIVE

To assess parents' and teachers' attitude towards Adolescent Reproductive Sexual Health Education (ARSHE).

METHODS

The study group consisted of a random sample of 795 parents and 115 teachers belonging to three urban schools (one boys only, one girls only and one co-education) and one co-education rural school at Thiruvananthapuram district, Kerala, where an ICMR supported ARSHE intervention programme was done subsequently. A self-administered questionnaire for parents and teachers developed by an ICMR taskforce for ARSHE programme was used to assess their opinion on the need, content and the appropriate person to provide adolescent reproductive sexual health education in a school setting.

RESULTS

65.2% of parents and 40.9% teachers have not discussed growth and development issues with their adolescents. Only 5.2% teachers and 1.1% parents discussed sexual aspects with adolescents. 44% of parents agreed that information on HIV/AIDS/STD should be provided. More than 50% of parents were not sure whether information on topics like masturbation, dating, safe sex, contraceptives, pregnancy, abortion and childcare should be provided to adolescents.

CONCLUSIONS

Results pointed out the need for introducing reproductive and sexual education in the school setting. Only 1.1% of parents and 5.2% teachers actually discussed sexual aspects with adolescents which highlights the need for parent and teacher awareness programs before ARSHE is introduced in the schools.

Complement independent antibody-mediated endarteritis and transplant arteriopathy in mice

Complement fixation, as evidenced by C4d in the microvasculature, is a widely accepted criterion of antibody-mediated rejection. Complement fixation has been shown to be essential in acute antibody-mediated rejection, but its role in chronic rejection has not been addressed. Previous studies showed that passive transfer of complement fixing monoclonal IgG2a anti-H-2Kk into B6.RAG1-/- KO recipients of B10.BR hearts led to progressive chronic transplant arteriopathy (CTA) over 14-28 days, accompanied by C4d deposition. The present studies were designed to test whether complement was required for these lesions. We report that a noncomplement fixing donor-specific alloantibody (DSA, monoclonal IgG1 anti-H-2Kk) injected into B6.RAG1-/- KO recipients of B10.BR hearts also promotes CTA, without C4d deposition. Furthermore, a passive transfer of DSA (monoclonal IgG2a anti-H-2Kk) initiated endarteritis followed by CTA in B6.RAG1-/- mice genetically deficient in the third component of complement (RAG1-/-C3-/-). These studies indicate that antibody to class I MHC antigens can trigger chronic arterial lesions in vivo without complement participation, in contrast to acute antibody-mediated rejection. This pathway may be relevant to C4d-negative chronic rejection sometimes observed in patients with DSA, and argues that lack of C4d deposition does not exclude antibody-mediated chronic rejection.

Association between neuropsychiatric morbidity and streptococcal infections in children

We conducted a case control study to study the association between neuropsychiatric morbidity and group A streptococcal infections in children. Twenty two cases of neuropsychiatric morbidity were compared with 64 controls. Fourteen (63.6%) of the 22 cases were positive for ASO and/or ADNB while 21 of the 64 controls (32.8%) were positive for either or both antibodies (OR = 3.428; CI: 1.15-10.18; P=0.026). We conclude that there is a statistically significant association between neuropsychiatric morbidity and streptococcal infection in children.

Validation of developmental assessment tool for Anganwadis (DATA)

OBJECTIVE

To develop, standardize, and partly validate a developmental scale for toddlers (age, 1.6 to 3 years) attending anganwadis in India.

METHODS

After the development of the 12-item Developmental Assessment Tool for Anganwadis (DATA), its internal consistency, face validity, content validity and construct validity were studied in 100 toddlers in anganwadis and were found to be appropriate. A total of 429 toddlers with a mean (SD) age of 30.9(5.2) months from 36 randomly selected anganwadis were recruited for its standardization. Raw scores were converted to standardized T-scores. Scoring pattern for domains and aggregate developmental scores were formulated.

RESULTS

Except for one item in the original scale, all the items were endorsed by parents suggesting a good content validity. Cronbachs a of 0.86 suggested a high internal consistency. Factor analysis replicated the 2 factor structure explaining 56 %of variance. An aggregated developmental score based on the standardized T-scores demonstrated that a DATA score between 33 and 28 suggested at risk for developing developmental delays. A score of 27 suggested already delayed milestones. A score of 27 to 16 suggested a mild delay, a score of 15 to 5 suggested a moderate delay and 4 suggested a severe delay in development.

CONCLUSION

DATA is a brief, simple and psychometrically sound measure for use in anganwadis for identifying toddlers at risk or with developmental delays. Differentially identifying toddlers at risk or with developmental delay helps in referring them for appropriate interventions.

Macrophage depletion suppresses cardiac allograft vasculopathy in mice

Cardiac allograft vasculopathy (CAV) is a major source of late posttransplant mortality. Although numerous cell types are implicated in the pathogenesis of CAV, it is unclear which cells actually induce the vascular damage that results in intimal proliferation. Because macrophages are abundant in CAV lesions and are capable of producing growth factors implicated in neointimal proliferation, they are leading end-effector candidates. Macrophages were depleted in a murine heterotopic cardiac transplant system known to develop fulminant CAV lesions. C57BL/6 hearts were transplanted into (C57BL/6 x BALB/c)F(1) recipients, which then received anti-macrophage therapy with intraperitoneal carrageenan or i.v. gadolinium. Intraperitoneal carrageenan treatment depleted macrophages by 30-80% with minimal effects upon T, B or NK cells as confirmed by flow cytometry and NK cytotoxicity assays. Carrageenan treatment led to a 70% reduction in the development of CAV, as compared to mock-treated controls (p = 0.01), which correlated with the degree of macrophage depletion. Inhibition of macrophage phagocytosis alone with gadolinium failed to prevent CAV. Macrophages may represent the end-effector cells in a final common pathway towards CAV independent of T-cell or B-cell alloreactivity and exert their injurious effects through mechanisms related to cytokine/growth factor production rather than phagocytosis.

Athabasca Valles, Mars: A Lava-Draped Channel System

Athabasca Valles is a young outflow channel system on Mars that may have been carved by catastrophic water floods. However, images acquired by the High-Resolution Imaging Science Experiment camera onboard the Mars Reconnaissance Orbiter spacecraft reveal that Athabasca Valles is now entirely draped by a thin layer of solidified lava-the remnant of a once-swollen river of molten rock. The lava erupted from a fissure, inundated the channels, and drained downstream in geologically recent times. Purported ice features in Athabasca Valles and its distal basin, Cerberus Palus, are actually composed of this lava. Similar volcanic processes may have operated in other ostensibly fluvial channels, which could explain in part why the landers sent to investigate sites of ancient flooding on Mars have predominantly found lava at the surface instead.

Meter-Scale Morphology of the North Polar Region of Mars

Mars' north pole is covered by a dome of layered ice deposits. Detailed ( approximately 30 centimeters per pixel) images of this region were obtained with the High-Resolution Imaging Science Experiment on board the Mars Reconnaissance Orbiter (MRO). Planum Boreum basal unit scarps reveal cross-bedding and show evidence for recent mass wasting, flow, and debris accumulation. The north polar layers themselves are as thin as 10 centimeters but appear to be covered by a dusty veneer in places, which may obscure thinner layers. Repetition of particular layer types implies that quasi-periodic climate changes influenced the stratigraphic sequence in the polar layered deposits, informing models for recent climate variations on Mars.

A Closer Look at Water-Related Geologic Activity on Mars

Water has supposedly marked the surface of Mars and produced characteristic landforms. To understand the history of water on Mars, we take a close look at key locations with the High-Resolution Imaging Science Experiment on board the Mars Reconnaissance Orbiter, reaching fine spatial scales of 25 to 32 centimeters per pixel. Boulders ranging up to approximately 2 meters in diameter are ubiquitous in the middle to high latitudes, which include deposits previously interpreted as finegrained ocean sediments or dusty snow. Bright gully deposits identify six locations with very recent activity, but these lie on steep (20 degrees to 35 degrees) slopes where dry mass wasting could occur. Thus, we cannot confirm the reality of ancient oceans or water in active gullies but do see evidence of fluvial modification of geologically recent mid-latitude gullies and equatorial impact craters.

Beta 3 integrins regulate lymphocyte migration and cytokine responses in heart transplant rejection

Integrin alpha v beta 3 is important for cell survival, signaling and migration, particularly during angiogenesis and tumorigenesis, where it has been proposed as a therapeutic target. alpha v beta 3 is up-regulated following transplantation and beta 3 polymorphisms are associated with increased acute kidney rejection, suggesting that alpha v beta 3 may also play a role in transplant rejection. Here, using a model of allogeneic heart transplantation, we show that allograft survival is prolonged in beta 3 integrin-deficient (beta 3(-/-)) mice. This is associated with Th2-type immune responses and reduced T-cell infiltration into grafts and T cells from beta 3(-/-) mice show impaired adhesion and migration, consistent with a role for alpha v beta 3 in transmigration. These studies provide evidence that targeting beta 3 integrins impairs recruitment of effector cells and alters cytokine production, so prolonging graft survival. We also show that low doses of blocking antibodies against leukocyte function associated antigen-1 (LFA-1)/alpha L beta 2 and very late antigen-4 (VLA-4)/alpha 4 beta 1, when combined with deletion of beta 3, lead to long-term survival of allografts with no evidence of chronic rejection. Hence we provide strong mechanistic evidence supporting previous genetic studies, demonstrate the involvement of beta 3 integrins in both acute and chronic rejection and identify beta 3 as a new target for immunosuppressive therapy.

Prevalence of eating disorders and psychiatric comorbidity among children and adolescents

There are no prevalence or co-morbidity studies on eating disorders in India. This retrospective chart review studied the prevalence and psychiatric co-morbidity among juveniles with eating disorders. Forty-one cases with ICD 10 diagnosis of eating disorders were identified and analyzed. The prevalence of eating disorders was 1.25% Psychogenic vomiting was the commonest eating disorders and anorexia nervosa the emerging eating disorder. The most common co-morbidities were depression, intellectual disability, and dissociative disorder.

Chronic cardiac transplant arteriopathy in mice: relationship of alloantibody, C4d deposition and neointimal fibrosis

Murine heterotopic cardiac allografts were used to reveal some of the fundamental interrelationships between donor-specific alloantibodies (DSA), chronic transplant arteriopathy (CTA) and capillary C4d deposition. B10.BR recipients of B10.A hearts developed transient DSA and C4d deposition that peaked on day 7 and became undetectable at day 56 while CTA developed progressively. Male cardiac grafts in female recipients showed similar degrees of CTA at day 56 but never developed DSA or C4d deposition, indicating that T cell-mediated mechanisms are sufficient to produce CTA. Passive transfer of monoclonal IgG2a anti-H-2K(k) into B6.RAG1 KO recipients of B10.BR hearts over 14-28 days led to progressive CTA. If treatment was stopped on day 14, lesions showed little progression and had no C4d deposition or detectable DSA on day 42. If treatment was stopped on day 28 when the lesions were fully developed, no regression occurred over the next 28 days, even though C4d deposition and circulating antibody became undetectable. Therefore, a minimum threshold of antibody exposure is needed to cause CTA. Once the CTA develops, C4d may become negative after DSA disappears. Thus, serial samples are needed in clinical studies to ascertain the relevance of alloantibody to the lesions of chronic graft rejection.

Further evidence that NK cells may contribute to the development of cardiac allograft vasculopathy

In prior experiments, we found that recipients, even though specifically tolerant of donor antigens, will develop striking cardiac allograft vasculopathy (CAV) in allogeneic mouse heart transplants. This suggested that innate immune responses, in addition to conventional adaptive immunity, may be involved in the development of CAV. We accordingly performed transplants in the parental-to-F1 combination seeking supportive evidence of NK cell activity directed against the vessels of parental donor transplants as a manifestation of "hybrid resistance." When such lesions were indeed found, we investigated their pathogenesis employing immunopathological analysis, in vitro measurements of NK cytotoxicity, and donor-specific T-cell activity in F1 recipients of parental donor hearts. We present evidence that NK cells can promote cardiac allograft vasculopathy. Since NK cell activity is not well targeted by current immunosuppressive therapy, its control may offer a valuable new possibility for improving the long-term outcome of transplanted organs.

Electro convulsive therapy in a pre-pubertal child with severe depression

Electro Convulsive Therapy (ECT) in pre-pubertal children is a controversial and underreported treatment. Even though the effectiveness and side effects of ECT in adolescents are comparable with those in adults, there is a pervasive reluctance to use ECT in children and adolescents. We report the case of a pre-pubertal child in an episode of severe depression with catatonic features, where a protracted course of ECT proved life-saving in spite of prolonged duration of seizures and delayed response to treatment. The case illustrates the safety and efficacy of ECT in children. Relevant literature is also reviewed along with the case report.

Tolerance, mixed chimerism, and chronic transplant arteriopathy

Much evidence supports the conclusion that immunological responses to donor-specific incompatibilities are a major factor in producing "chronic" transplant rejection, including the arteriopathy (atherosclerosis) commonly present. Our experiments explored the effects of altered immunological responsiveness to these Ags on the formation of arteriopathy in transplanted mouse hearts. Specific immunological nonreactivity, or tolerance, was induced either by neonatal administration of allogeneic spleen cells (from F(1) donors between class I-mismatched donor and recipient strains), resulting in "classical" immunological tolerance, or by bone marrow infusion to suitably prepared adult recipients, either fully MHC mismatched or class I mismatched, yielding "mixed chimerism." Both approaches obviated systemic graft-versus-host effects. In both groups, donor-specific skin grafts survived perfectly and donor cell chimerism persisted. Specific Abs were undetectable in all recipients. Most transplants to either group of tolerant recipients developed striking vasculopathy in their coronary arteries (12 of 15 in neonatal tolerance and 15 of 23 in mixed chimeras). Neointimal infiltrates included CD4 and CD8 T cells and macrophages. Only 2 of 29 contemporary isotransplants showed any evidence of vasculopathy. Recipients essentially incapable of T and B cell responses (C.B-17/SCID and RAG1(-/-)) were also used. Transplants into these animals developed vasculopathy in 16 of 31 instances. Accordingly, in this setting, vasculopathy develops in the presence of H-2 gene-determined incompatibility even with minimal conventional immune reactivity. Perhaps innate responsiveness, that could include NK cell activity, can create such arteriopathic lesions. More evidence is being sought regarding this process.

Induction of molecular chimerism by gene therapy prevents antibody-mediated heart transplant rejection

In order for xenotransplantation to become a clinical reality, and fulfill its promise of overcoming shortages of human organs and tissues, rejection mediated by the host's immune system must first be overcome. In primates, preformed natural antibodies that bind the carbohydrate antigen Galalpha1-3Galbeta1-4GIcNAc-R (alphaGal), which is synthesized by UDP galactose:beta-D-galactosyl-1,4-N-acetyl-D-glucosaminide alpha(1-3)galactosyltransferase (E.C. 2.4.1.151) or simply alphaGT, mediate rigorous rejection of transplanted pig organs and tissues. In alphaGT knockout mice (GT0 mice), which like humans contain in their serum antibodies that bind alphaGal, expression of a retrovirally transduced alphaGT in bone marrow-derived cells is sufficient to prevent production of alphaGal-reactive antibodies. Here, we demonstrate that reconstitution of lethally irradiated GT0 mice with alphaGT-transduced bone marrow cells from GT0 littermates prevents antibody-mediated rejection of cardiac transplants from wild-type mice. These data suggest that gene therapy can be used to induce immunological tolerance to defined antigens and thereby overcome transplant rejection.

Fundamental-mode cutoff in a photonic crystal fiber with a depressed-index core

We report a photonic crystal fiber with a depressed-index core doped with fluorine. The effective index of the cladding matches that of the core at an antiguiding wavelength, below which the fiber does not guide light at all.

White-light supercontinuum generation with 60-ps pump pulses in a photonic crystal fiber

The generation of a spatially single-mode white-light supercontinuum has been observed in a photonic crystal fiber pumped with 60-ps pulses of subkilowatt peak power. The spectral broadening is identified as being due to the combined action of stimulated Raman scattering and parametric four-wave-mixing generation, with a negligible contribution from the self-phase modulation of the pump pulses. The experimental results are in good agreement with detailed numerical simulations. These findings demonstrate that ultrafast femtosecond pulses are not needed for efficient supercontinuum generation in photonic crystal fibers.

White-light frequency comb generation with a diode-pumped Cr:LiSAF laser

We have created a broad spectrum spanning more than an optical octave by launching femtosecond pulses from a battery operated Cr:LiSAF laser into a photonic crystal fiber. Despite the massive broadening in the fiber, the comb structure of the spectrum is preserved, and this frequency comb is perfectly suited for applications in optical frequency metrology.

Miniature all-fiber devices based on CO(2) laser microstructuring of tapered fibers

A focused carbon dioxide laser beam is used to microstructure fibers that have already been narrowed by conventional fiber tapering. We describe three new miniature devices made with this technique: a fused fiber microcoupler with an interaction length of 200 mum, a long-period grating made from a periodic chain of microtapers, and a new type of prolate whispering-gallery mode microcavity.

Simultaneous generation of spectrally distinct third harmonics in a photonic crystal fiber

By coupling femtosecond pulses at lambda - 1.55mum in a short length (Z - 95 cm) of photonic crystal fiber, we observe the simultaneous generation of two visible radiation components. Frequency-resolved optical gating experiments combined with analysis and modal simulations suggest that the mechanism for their generation is third-harmonic conversion of the fundamental pulse and its split Raman self-shifted component.

Vertical-cavity surface-emitting resonances in photonic crystal films

It is shown that thin films of dielectric, etched through with a suitably chosen lattice of holes, can support surface-emitting vertical resonances with very-high-cavity Q factors (approximately 10(5) in the case of Al(x)GaAs(1-x) on oxidized AlyGaAs1-y). A Bloch-wave expansion is used to develop a complete vector-field analysis of these resonances and to reveal their underlying physics. Since they do not require multilayer mirrors, such resonators are a practical and simple replacement for conventional vertical-cavity surface-emitting laser structures. Other applications include wavelength-division-multiplexing components and highly sensitive gas detectors.

Excitation of cladding modes in photonic crystal fibers by flexural acoustic waves

We report the excitation by flexural acoustic waves of an individual cladding mode in a single-mode photonic crystal fiber. The propagation constant and the field distributions of the mode have been investigated by use of this technique. The results give the basis for developing a family of acousto-optic devices based on photonic crystal fibers.

Supercontinuum generation in tapered fibers

Supercontinuum light with a spectrum more than two octaves broad (370-1545 nm at the 20-dB level) was generated in a standard telecommunications fiber by femtosecond pulses from an unamplified Ti:sapphire laser. The fiber had been tapered to a diameter of :2mum over a 90-mm length. The pulse energy was 3.9 nJ (average power, 300 mW). This source of high-intensity single-mode white light should find widespread applications in frequency metrology and spectroscopy, especially since no unconventional fibers are needed.

Highly birefringent photonic crystal fibers

We report a strongly anisotropic photonic crystal fiber. Twofold rotational symmetry was introduced into a single-mode fiber structure by creation of a regular array of airholes of two sizes disposed about a pure-silica core. Based on spectral measurements of the polarization mode beating, we estimate that the fiber has a beat length of approximately 0.4 mm at a wavelength of 1540 nm, in good agreement with the results of modeling.

Optical frequency synthesizer for precision spectroscopy

We have used the frequency comb generated by a femtosecond mode-locked laser and broadened to more than an optical octave in a photonic crystal fiber to realize a frequency chain that links a 10 MHz radio frequency reference phase-coherently in one step to the optical region. By comparison with a similar frequency chain we set an upper limit for the uncertainty of this new approach to 5. 1x10(-16). This opens the door for measurement and synthesis of virtually any optical frequency and is ready to revolutionize frequency metrology.