Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Human papillomavirus related oropharyngeal cancer: identifying and quantifying topics of patient interest

OBJECTIVE

As the incidence of human papillomavirus related oropharyngeal cancer continues to rise, it is increasingly important for public understanding to keep pace. This study aimed to identify areas of patient interest and concern regarding human papillomavirus and oropharyngeal cancer.

METHOD

This study was a retrospective survey of search queries containing the keywords 'HPV cancer' between September 2015 and March 2021.

RESULTS

There was 3.5-fold more interest in human papillomavirus related oropharyngeal cancer (15 800 searches per month) compared with human papillomavirus related cervical cancer (4500 searches per month). Among searches referencing cancer appearance, 96.8 per cent pertained to the head and neck region (3050 searches per month). Among vaccination searches, 16 of 47 (34.0 per cent; 600 searches per month) referenced human papillomavirus vaccines as being a cause of cancer rather than preventing cancer.

CONCLUSION

The vast majority of online searches into human papillomavirus cancer pertain to the oropharynx. There are relatively few search queries on the topic of vaccination preventing human papillomavirus associated oropharyngeal cancer, which highlights the continued importance of patient education and awareness campaigns.

Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial

OBJECTIVES

Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India.

METHODS

Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials.

RESULTS

Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group.

CONCLUSIONS

The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

Spongiform leukoencephalopathy: A unique case of biopsy confirmed leukoencephalopathy secondary to toxic, non-inflammatory exposure

Toxin-induced leukoencephalopathy is a rare neurological condition that has been previously associated with intracranial radiation, chemotherapy, drugs of abuse, and environmental exposures. Herein, we present a patient with brain-biopsy proven toxin-induced leukoencephalopathy, likely secondary to multiple environmental offenders including insecticides and non-Food and Drug Administration approved anabolic steroids, opioids, and benzodiazepines. A 60-year-old man presented to our service as a direct transfer from an outside facility for evaluation of a rapidly progressive neuropsychiatric decline. Extensive workup with blood work, cerebrospinal fluid analysis, paraneoplastic panel, serial magnetic resonance imaging brain with and without contrast, and electroencephalograms were unrevealing. Magnetic resonance imaging brain showed diffuse confluent white matter disease, which was non-specific. The patient was treated with high-dose methylprednisolone and trials of intravenous immunoglobulin without any significant improvement. Finally, a brain biopsy was performed, and pathology confirmed a spongiform leukoencephalopathy, favoring a toxin-related etiology. The diagnosis of toxin-induced leukoencephalopathy should be considered in patients with steep neuropsychiatric decline and associated diffuse white matter disease. Diagnosis relies heavily on history of exposure, clinical presentation, imaging findings, and ultimately, histopathology from brain biopsy. The recognition of the clinical presentation is important to pursue the appropriate diagnostic workup and treatment.

Impact of subcutaneous immunoglobulin on quality of life in patients with chronic inflammatory demyelinating polyneuropathy previously treated with intravenous immunoglobulin

INTRODUCTION/AIMS

Intravenous immunoglobulin (IVIg) is a common therapy for patients with chronic inflammatory demyelinating polyneuropathy (CIDP). IVIg may cause systemic adverse events (AEs); therefore, infusion of subcutaneous immunoglobulin (SCIg) may be preferred by some patients. In this study we document the experiences of patients transitioning from IVIg to SCIg.

METHODS

Transitioning subjects with CIDP were followed in a 6-month prospective, open-label study. The primary endpoint was percentage of subjects who withdrew for any reason (including significant AEs). The secondary endpoint was symptom progression or relapse requiring a change in management. Quality of life (QOL) and treatment satisfaction were assessed using the Short Form 36-item Health Survey (SF-36), Treatment Satisfaction Questionnaire for Medication (TSQM), and Chronic Acquired Polyneuropathy Patient-Reported Index (CAP-PRI). Efficacy was assessed using the Inflammatory Rasch-built Overall Disability Scale, hand-held dynamometry, limb motor strength testing (LMST), and timed 25-ft walk (T25-FW).

RESULTS

Fifteen CIDP subjects transitioned from IVIg to SCIg. Of these, three (20%) met the primary endpoint and one (7%) met the secondary endpoint. The SF-36 showed a statistically significant improvement for the domain of role limitations-physical after 24 weeks (P = .03), with no significant differences observed in other domains. TSQM and CAP-PRI showed significant differences in favor of SCIg (P = .003 and .02, respectively). No significant differences were observed in efficacy after 24 weeks, except for LMST, which favored SCIg (P = .003). Eight of the 12 study completers (67%) continued with SCIg.

DISCUSSION

Transition to SCIg was associated with maintained efficacy and improved QOL.

Discovery and Validation of a Three-Cytokine Plasma Signature as a Biomarker for Diagnosis of Pediatric Tuberculosis

Pediatric TB poses challenge in diagnosis due to the paucibacillary nature of the disease. We conducted a prospective diagnostic study to identify immune biomarkers of pediatric TB and controls (discovery cohort) and obtained a separate “validation” cohort of confirmed cases of pediatric TB and controls. Multiplex ELISA was performed to examine the plasma levels of cytokines. Discovery and validation cohorts revealed that baseline plasma levels of IFNγ, TNFα, IL-2, and IL-17A were significantly higher in active TB (confirmed TB and unconfirmed TB) in comparison to unlikely TB children. Receiver operating characteristics (ROC) curve analysis revealed that IFNγ, IL-2, TNFα, and IL-17A (in the discovery cohort) and TNFα and IL-17A (in the validation cohort) could act as biomarkers distinguishing confirmed or unconfirmed TB from unlikely TB with the sensitivity and specificity of more than 90%. In the discovery cohort, cytokines levels were significantly diminished following anti-tuberculosis treatment. In both the cohorts, combiROC models offered 100% sensitivity and 98% to 100% specificity for a three-cytokine signature of TNFα, IL-2, and IL-17A, which can distinguish confirmed or unconfirmed TB children from unlikely TB. Thus, a baseline cytokine signature of TNFα, IL-2, and IL-17A could serve as an accurate biomarker for the diagnosis of pediatric tuberculosis.

Eculizumab during Pregnancy in a Patient with Treatment-Refractory Myasthenia Gravis: A Case Report

The recombinant humanized monoclonal antibody eculizumab has been shown to be effective and well tolerated in patients with anti-acetylcholine receptor antibody-positive, treatment-refractory generalized myasthenia gravis (gMG). Myasthenia gravis (MG) often affects women of child-bearing potential. However, management can be challenging during pregnancy, and current treatment options are limited due to potential teratogenicity. Data are currently lacking on the use of eculizumab in pregnant women with gMG. This case report describes a successful pregnancy in a young woman with treatment-refractory gMG treated with eculizumab before, during, and after pregnancy. Eculizumab appeared to have a favorable benefit-risk profile in this setting, with no treatment-related adverse effects noted in either the patient or the neonate. The patient remains neurologically stable on eculizumab, which she has now been receiving for 5 years. This first report of the use of eculizumab during pregnancy in a patient with treatment-refractory gMG suggests a potential role for eculizumab in this setting, although further clinical experience is necessary to support its use during pregnancy in women with MG.

Effect of preoperative oral administration of steroids in comparison to an anti-inflammatory drug on postoperative pain following single-visit root canal treatment - a double-blind, randomized clinical trial

AIM

This randomized, double-blinded, clinical trial evaluated the effect of oral premedication of piroxicam, prednisolone, dexamethasone or placebo on postoperative pain after single-visit root canal treatment in teeth with symptomatic irreversible pulpitis and symptomatic apical periodontitis.

METHODOLOGY

The trial is reported according to the Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 guidelines. The protocol was registered at the clinical trial registry (India) (CTRI/2019/06/019818). In total, 160 patients, assigned to four groups, received orally either 20 mg piroxicam, 20 mg prednisolone, 4 mg dexamethasone or a placebo 60 min before root canal treatment. Patients recorded their postoperative pain intensity at 6, 12, 24, 48 and 72 h using a 10-cm visual analogue scale. Intergroup comparison was performed using Kruskal-Wallis tests with post hoc analysis using Dunns test. Incidence of pain was analysed using chi-square tests. A P value < 0.05 was considered to be statistically significant. Binary logistic regression was used to determine the odds of postoperative pain, with incidence of pain as the dependent variable and intervention groups, gender, age and type of tooth as independent variables.

RESULTS

In total, 156 patients were analysed in the trial, since four patients dropped out during follow-up. All drugs were associated with a significantly lower incidence of postoperative pain compared to the placebo at 6 h (P = 0.009), 12 h (P = 0.003) and 24 h (P = 0.008). Mean intensity of pain was significantly more intense at 6, 12 and 24 h with the use of placebo in comparison to the other three intervention groups (P < 0.05). Intensity of pain was not significantly different between the premedications used (P > 0.05). One patient in the piroxicam group reported gastritis, whereas no adverse effects were recorded in other groups.

CONCLUSION

Preoperative oral administration of a single dose of 4 mg dexamethasone, 20 mg piroxicam or 20 mg prednisolone reduced the incidence and severity of postoperative pain following single-visit root canal treatment compared to a placebo in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis up to 24 h. The odds of postoperative pain at 24 h for patients premedicated with 4 mg dexamethasone or 20 mg piroxicam or 20 mg prednisolone were 5.3 times, 3.4 times and 2.5 times less compared to the placebo, respectively.

Algorithmic assessment of missense mutation severity in the Von-Hippel Lindau protein

Von Hippel-Lindau disease (VHL) is an autosomal dominant rare disease that causes the formation of angiogenic tumors. When functional, pVHL acts as an E3 ubiquitin ligase that negatively regulates hypoxia inducible factor (HIF). Genetic mutations that perturb the structure of pVHL result in dysregulation of HIF, causing a wide array of tumor pathologies including retinal angioma, pheochromocytoma, central nervous system hemangioblastoma, and clear cell renal carcinoma. These VHL-related cancers occur throughout the lifetime of the patient, requiring frequent intervention procedures, such as surgery, to remove the tumors. Although VHL is classified as a rare disease (1 in 39,000 to 1 in 91,000 affected) there is a large heterogeneity in genetic mutations listed for observed pathologies. Understanding how these specific mutations correlate with the myriad of observed pathologies for VHL could provide clinicians insight into the potential severity and onset of disease. Using a select set of 285 ClinVar mutations in VHL, we developed a multiparametric scoring algorithm to evaluate the overall clinical severity of missense mutations in pVHL. The mutations were assessed according to eight weighted parameters as a comprehensive evaluation of protein misfolding and malfunction. Higher mutation scores were strongly associated with pathogenicity. Our approach establishes a novel in silico method by which VHL-specific mutations can be assessed for their severity and effect on the biophysical functions of the VHL protein.

An Open-Label, Prospective Study Evaluating the Clinical and Immunological Effects of Higher Dose Granulocyte Colony-Stimulating Factor in ALS

OBJECTIVE

We evaluated the safety and tolerability of higher-dose granulocyte colony-stimulating factor (G-CSF) in patients with amyotrophic lateral sclerosis. In addition, rates of disease progression and serum G-CSF levels and other immunological and hematological markers were measured.

METHODS

Three patients with advanced amyotrophic lateral sclerosis were treated with G-CSF subcutaneously at 5 μg/kg twice daily for 5 consecutive days monthly for 4-12 months. Patients were monitored for adverse effects, and disease progression was assessed with ALSFRS-R and other measures.

RESULTS

Patients tolerated higher-dose G-CSF well with no serious adverse events. Adverse effects were mild to moderate with musculoskeletal pain and malaise being most often reported. No significant change in the rate of disease progression was noted for ALSFRS-R or other measures. Bone marrow progenitor cells were rapidly mobilized for a duration of approximately 9 days with transient and variable effect on cytokines.

CONCLUSIONS

Higher-dose G-CSF was well tolerated in this cohort with no apparent effect on disease progression up to 1 year.

Effect of NaCl on the properties of sulphamic acid single crystals

Single crystals of pure and NaCl doped sulphamic acid (SA) were grown by slow evaporation method at room temperature. The lattice parameters and structure were determined by using single crystal and powder X-ray diffraction analyses. The presence of dopant in the SA lattice was affirmed by EDAX analysis. UV-Vis spectra show maximum transmittance in the visible region. The band gap energies were found to be 6.06 eV and 5.70 eV for pure and NaCl doped SA crystals respectively. From the PL specta the emission were observed at 335 and 424 nm for pure and 340 and 428 nm for doped SA crystal. The thermal stability of the grown crystals were analyzed by thermogravimetric and differential thermal analysis (TGA/DTA) and revealed that the grown crystals were thermally stable up to 331 °C and 334 °C for pure and NaCl doped SA. Vickers microhardness study reveals that the hardness of the crystals is increase with increasing load. The photoconductivity study shows that the grown crystals are negative photoconductive nature. The Laser Damage Threshold (LDT) indicates the grown crystals have good resistance to laser radiation than a standard Potassium dihydrogen phosphate (KDP) crystal. The Z-scan technique was employed to determine the nonlinear refractive index, nonlinear optical absorption and third order nonlinear optical (TONLO) susceptibility of the grown crystals using He–Ne laser.

Mechanisms of artemisinin resistance in Plasmodium falciparum malaria

Artemisinin-based combination therapies (ACTs) have substantially reduced worldwide malaria burden and deaths. But malaria parasites have become resistant to artemisinins. Prior studies suggested two different molecular pathways of artemisinin-resistance. Here we unify recent findings into a single model, where elevation of a lipid, phosphatidylinositol-3- phosphate (PI3P) results in vesicle expansion that increases the engagement with the unfolded protein response (UPR). Vesicle expansion (rather than increasing individual genetic determinants of the UPR) efficiently induces artemisinin resistance likely by promoting ‘proteostasis’ (protein translation coupled to proper protein folding and vesicular remodeling) to mitigate artemisinin-induced proteopathy (death from global abnormal protein-toxicity). Vesicular amplification engages the host red cell, suggesting that artemisinin resistant malaria may also persist by taking advantage of host niches and escaping the immune response.

A 6-year-old boy with Wilson disease-A diagnostic dilemma

A 6-year-old boy presented with 2 months history of progressive abdominal distension and jaundice. He was deeply icteric with ascites, hepatosplenomegaly, hyperbilirubinemia, raised transaminases, and coagulopathy. Viral markers and slit lamp examination for Kayser-Fleischer ring were negative. Serum ceruloplasmin and 24-h urinary copper post-D-pencillamine challenge were normal. Anti-smooth muscle antibody was positive 1:20, and liver biopsy showed micronodular cirrhosis with abundant Mallory hyaline and stainable copper deposits. The liver histology was indicative of Indian childhood cirrhosis, whereas the presence of autoantibodies, elevated transaminases, and increased globulin was suggestive of autoimmune hepatitis. Gene studies identified p.R969Q mutation in ATP7B gene, which solved the dilemma and confirmed the diagnosis of Wilson disease (WD). We report a clinicopathological conference of this boy to highlight the challenges faced by pediatricians in the diagnosis of Wilson disease. ᅟ.

Dielectric versus magnetic pairing mechanisms in high-temperature cuprate superconductors investigated using Raman scattering

We suggest, and demonstrate, a systematic approach to the study of cuprate superconductors, namely, progressive change of ion size in order to systematically alter the interaction strength and other key parameters. R(Ba,Sr)2Cu3Oy (R={La,…,Lu,Y}) is such a system where potentially obscuring structural changes are minimal. We thereby systematically alter both dielectric and magnetic properties. Dielectric fluctuation is characterized by ionic polarizability while magnetic fluctuation is characterized by exchange interactions measurable by Raman scattering. The range of transition temperatures is 70-107 K, and we find that these correlate only with the dielectric properties, a behavior which persists with external pressure. The ultimate significance may remain to be proven, but it highlights the role of dielectric screening in the cuprates and adds support to a previously proposed novel pairing mechanism involving exchange of quantized waves of electronic polarization.

Reference values for oxygen saturation by pulse oximetry in healthy children at sea level in Chennai

There is little information on oxygen saturation (SaO2) values in children in developing countries.

AIM

To determine the reference values for oxygen saturation by pulse oximetry in healthy children living at sea level in Chennai and aged between 1 mth and 5 yrs.

DESIGN AND SETTING

A prospective study was conducted in Kanchi Kamakoti CHILDS Trust Hospital from February to May 2005.

METHODS

A total of 626 healthy children aged between 1 mth and 5 yrs were examined for heart rate, respiratory rate and SaO2.

RESULTS

The mean SaO2 levels for children in the age groups 1-3 mths, 3 mths to 1 yr, 1-3 years and 3-5 years were 98.5%, 98.8%, 98.9% and 99.1%, respectively. The overall mean and median SaO(2) values for the children in the different age groups were 99%. The mean -2 SD values of oxygen saturation in the age groups were 96.5%, 96.4%, 96.3% and 97.1%, respectively, with an overall mean of 96.6%.

CONCLUSION

The reference value for mean SaO2 in healthy children aged between 1 mth and 5 yrs and living at sea level in Chennai city was 98.5% or more, but the -2SD values had a mean of 96.6%.

Head injuries in children resulting from the fall of television

Case records of children admitted with head injury due to TV fall in a pediatric tertiary care hospital in Chennai, during March 2007-February 2008 were analysed retrospectively. Out of the 11 children admitted 6 (54%) were in 1-2 yr age group. Bleeding from the ear, nose and throat was the commonest, finding followed by a skull fracture, seen on imaging studies. These were observed in 9 (81.81%) and 8 (72.8%) children respectively. There was no mortality.

Solitary rectal ulcer syndrome: a case series

A retrospective analysis of the clinical profile, endoscopic features and management of 22 children (age 18 months-18 years) diagnosed as solitary rectal ulcer syndrome is presented. The majority (81.8%) were ≥8 years of age. Rectal bleeding was the presenting feature in all the children. Mucorrhea, constipation, tenesmus and rectal prolapse were observed in 77.3%, 63.6%, 59% and 13.6% children, respectively. Colonoscopy showed classical single rectal ulcer in 68.2% and multiple ulcers in 22.7%. Polypoidal and erosive lesions were documented in 4.5% each. The medical management comprised of bowel training and high fibre diet for all children. The other modalities included oral 5-amino salicylate (59%), sucralfate enema (4.5%) and rectal mesalamine in 9%. 64% children recovered and 13.6% had recurrence of symptoms.

Chronic abdominal pain in children

Chronic abdominal pain (CAP) continues to be a diagnostic and therapeutic challenge. It affects about 10% of school-going children and adolescents. Few Indian studies have reported an organic cause in 30%-40% of children with recurrent abdominal pain. In developing countries, parasitic infestations such as giardiasis and ascariasis are an important cause, of recurrent abdominal pain but their frequency has decreased over time. There is a paucity of data from India on the aetiology, epidemiology and management strategies for CAP, and there is no consensus on the clinical approach to this problem. We present a practical approach to CAP in children. The first step is to elicit a detailed history and do a thorough physical examination so as to categorize CAP according to the site of pain (epigastric, periumbilical or left lower quadrant), the predominant symptom associated with pain (dyspepsia, isolated pain or altered bowel habits) and to differentiate the pain as organic or functional based on the characteristics of pain and presence or absence of alarm signs. The second step is to do appropriate investigations, restricted to simple tests when functional pain is suspected (Level I) and more investigations (Level Ia) if there are alarm signs and pain appears to be organic in nature. Invasive investigations such as gastrointestinal endoscopy (Level II) may be reserved for those with possible organic pain. Level III investigations need to be done in a small percentage of children and include EEG, workup for food allergy and porphyria. The third step is management of organic CAP according to the aetiology, while for functional CAP the pharmacological and, rarely, psychological intervention is more difficult but should be done discreetly and tailored to the needs of the child.

Primary intestinal lymphangiectasia

Primary intestinal lymphangiectasia (PIL) is a rare disease of intestinal lymphatics presenting with hypoproteinemia, bilateral lower limb edema, ascites, and protein losing enteropathy. We report a series of 4 children from Chennai, India presenting with anasarca, recurrent diarrhea, hypoproteinemia and confirmatory features of PIL on endoscopy and histopathology.

Comparison of oxygen saturation levels by pulse oximetry in healthy children aged 1 month to 5 years residing at an altitude of 1500 metres and at sea level

OBJECTIVE

To compare oxygen saturation levels (SaO(2)) by pulse oximetry among healthy Indian children aged from 1 month to 5 years age residing at two different altitudes, Chennai and the Shervaroy hills.

DESIGN

Prospective observational study with a control group at sea level. SETTING 1: Chennai city which is at sea level (data published previously). SETTING 2: The Shervaroy hills (Yercaud, Salem district, Tamil Nadu) about 1500 metres above sea level (this study).

SUBJECTS

328 healthy children aged 1 month to 5 years living in the Shervaroy hills.

OUTCOME MEASURES

After assessment of anthropometry and heart and respiratory rates, oxygen saturation was recorded by pulse oximetry.

RESULTS

The mean SaO(2) values of children in the Shervaroy hills in the age groups 1 month to 3 years and 3-5 years were 97% and 98%, respectively. The mean -2 SD O(2) saturation values for the 1 month to 5 years age group was 93%. The overall mean and median values of oxygen saturation were 97% in the Shervaroy hills vs 99% for children in Chennai city (p<0.01). When compared with their counterparts in Chennai, the Shervaroy hills subjects had significantly lower mean weight and height and higher heart and respiratory rates (p<0.01).

CONCLUSION

The reference value for mean SaO(2) in healthy children aged 1 month to 5 years in the Shervaroy hills (1500 m) was 97%, with the (-2 SD) values having a mean of 93% which is significantly lower than those living in Chennai (sea level), 99% of whom had a -2 SD mean of 96.6%.

Effect of cadmium chloride on liver, spleen and kidney melano macrophage centres in Tilapia mossambica

To study the toxic effect of a heavy metal on the occurrence of melano macrophage centres (MMC) of liver, spleen and kidney. Tilapia mossambica were exposed to median lethal concentration of cadmium chloride for 120 hours. Routine histological method was adopted to prepare the tissue sections and to identify the pigments viz: hemosiderin and melanin. The average number and size of melano macrophage centres (MMC) were significantly increased compared with the control. It is evident in the present study that in the MMC of all three tissues examined lipofuscin is absent.

A prospective audit to investigate the level of consciousness of children requiring conscious sedation using an 'alternative technique'

The aim of this prospective pragmatic audit was to investigate the level of consciousness experienced by children requiring conscious sedation in a primary care sedation service, using an 'alternative technique' to avoid referral to hospital for general anaesthesia. This technique was only applied to children who were unable to accept treatment with the use of standard inhalation sedation. The technique involved titrated inhaled oxygen and nitrous oxide and titrated sevoflurane with intravenous fentanyl and titrated midazolam. The described technique was provided by an experienced team with appropriate facilities that complied with contemporary standards and guidance. During treatment and recovery the consciousness level of children was recorded using a modified Wilson's scale. Of the sample of 573 children who received the audited technique, 1.9% (11 children) scored level 5 on the modified Wilson scale (eyes closed but responsive to mild physical stimulus). Due to the fine control this technique offers, the duration of this level of consciousness was for mostly less than a minute and no more than five minutes. No children became unresponsive. The results of this audit demonstrate that the technique meets current standards and guidelines for 'alternative' conscious sedation, with a wide margin of safety and the rendering of loss of consciousness unlikely. 99% of patients who would otherwise have required general anaesthetic for dental treatment successfully completed their treatment using this technique.

Evaluation of chronic abdominal pain--a test of "patience"

A 4 year old girl with chronic abdominal pain of 6 months duration was provisionally diagnosed as eosinophilic gastroenteritis based on endoscopic biopsy This case is reported for its rarity.

The adaptation to salinity: protein synthesis and some aspects of energy transduction in fish gill mitochondria

Exposure of freshwater fish to saline conditions brings about somewhat drastic changes in the mitochondrial energy metabolism. These include abolition of oxidative phosphorylation, ATP-induced contraction of swollen mitochondria and transhydrogenase activity. On the other hand the endogenous calcium levels and protein synthetic capacity are elevated. In vitro protein synthesis by mitochondria from freshwater and stressed fish shows qualitative and quantitative variations. Effluxing the excess calcium by treatment with NaCl or inhibiting the protein synthesis by chloramphenicol in stressed mitochondria restores almost all the functions. It is proposed that the energy potential formed by the mitochondrial membrane is channelized to perform different functions and that the ratio of channelization can be altered to suit the needs of the cell.

Pericardial tamponade in neonate following migration of a sialastic central venous catheter

Central venous catheters constitute an essential part of most neonatal intensive care units (NICU). However, they are known to be associated with several complications. We here with report a rare lethal complication of pericardial effusion with cardiac tamponade occurred in a term neonate following central venous line.

Diabetic ketoacidosis in children

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). The frequency of DKA at the onset of DM correlates inversely with the incidence of type 1 DM and is more common in young children, children without a first degree relative with type 1 DM and individuals whose families are from a lower socioeconomic status. The mortality rate for DKA in children is 0.15%-0.3%. A high index of suspicion with timely administration of appropriate intravenous fluids, rational use of sodium bicarbonate, continuous rather than bolus insulin infusion and monitoring in an intensive care unit are associated with a better outcome.

Crohn's disease presenting as palatal ulcer

Crohn's disease (CD) in children younger than 5 years of age is termed as early onset inflammatory bowel disease (EO-IBD). We report a 4 yr 6 mo-old child with EO-IBD, who presented with palatal ulcer, an extra intestinal manifestation of Crohn's disease as the dominant feature.

Vanishing CT lesions in epilepsy

Experience with computed tomography (CT) in patients with epilepsy has drawn attention to specific type of cerebral lesions widely prevalent in this part of the world. The lesions disappear spontaneously while patients receive only anticonvulsant therapy. The exact nature of these lesions is not yet understood. One-hundred and twenty-two such patients (M 77; F 45) were studied. Their age ranged from 3 to 57 (mean 21.8 +/- 12.7) years. Seizures were partial motor in 86 (70.5%), generalised tonic clonic in 31 (25.4%), complex partial in 4 and atonic in one case. Postictal hemiparesis was seen in 6 patients who completely recovered within 5 min to 7 days. One hundred patients underwent EEG examination. It was abnormal in 84 cases; 40 patients showed localisation which correlated with CT findings. Plain CT showed low attenuation lesions in all cases. Morphology on contrast enhancement was ring lesion in 50 (40.9%), disc lesion in 47 (38.5%), target lesion in 3 (2.5%), mixed lesion in 2 (0.8%), no enhancement in 18 (14.8%) and a speck with oedema in 2 (0.8%) cases. All lesions were cerebral, present at cortical-subcortical junction. The first follow-up scan was performed in 78 (63.9%) patients within 6-12 weeks. It showed complete disappearance of the lesion in 47 (60.3%) cases. Reduction in size of the lesion and surrounding oedema was observed in 24 (30.8%) cases. The follow-up scans in these 24 cases revealed disappearance of lesion in 11 cases and almost complete resolution of the lesion with a remaining speck in 13 cases. Cerebrospinal fluid (CSF) was normal in 95 out of 100 cases in which it was performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired aphasia with epilepsy--Landau-Kleffner syndrome

Landau-Kleffner syndrome is characterized by long-lasting acquired aphasia associated with seizures and EEG abnormalities. Three new cases of this rare syndrome are reported from India.