Study of immunization status of under: five children in relation to various demographic variables of their mothers

Background: Immunization remains an important public health intervention. On one side morbidity and mortality caused by vaccine-preventable diseases are still high in developing countries, on the other side immunization coverage is still low. Present study aims to assess immunization status of under-five children in relation to various demographic variables of their mothers.Methods: A total of 530 mothers with children under 5 years attending OPD, immunization clinic or admitted in paediatric ward were included in the study. Maternal demographic variables like age, religion, education, socio economic status, residence, parity and occupation were compared with immunization status of their children.Results: Most of mothers were housewives (73.77%), primary educated (33.58%), belonged to Hindu religion (47.54%), were of 21-30 years age group (52.64%), residing in urban areas (62.07%) and belonged to middle socio economic status (45.84%). Out of total 530 children 161 (30.37%) were completely immunized as compared to 21.32% who were unimmunized. Boys were marginally more unimmunized (37.32%) than girls (23.04%). Mothers' education, occupation, parity, religion, residence and socio-economic status significantly influenced immunization status of their children (p<0.05).Conclusions: Therefore, it is recommended that any strategy formulated to improve vaccination coverage in children of our country should focus to strengthen above mentioned weak links.

Clinical profile and outcome of neonatal thrombocytopenia in a tertiary care hospital

Background: Thrombocytopenia (platelet count <1,50,000/'L) is one of the most common haematological problems in neonatal intensive care units. In contrast, only 2% of the normal neonates are thrombocytopenic at birth with severe thrombocytopenia (platelet count <50,000/'L) occurring in less than 3/1000 term infants. Multiple disease processes can cause thrombocytopenia in neonates. The important causes of thrombocytopenia in neonates are sepsis, birth asphyxia, prematurity, intra-uterine growth retardation, hyperbilirubinemia, respiratory distress syndrome, meconium aspiration syndrome and low birth weight. Apart from platelet count, bleeding manifestations depend on underlying ailments. The aims and objective were to study the clinical profile, etiology and outcome of neonatal thrombocytopenia in a tertiary care hospital.Methods: Prospective study involving 100 neonates with or developed neonatal thrombocytopenia in NICU.Results: In present study, 100 new-borns with thrombocytopenia 46% were mild, 35% were moderate and 19% were severe thrombocytopenia. 51 (51%) had early onset neonatal thrombocytopenia and 49 (49%) babies had late onset neonatal thrombocytopenia. Anaemia was the dominant maternal predisposing risk factor. Sepsis was the most common cause of neonatal thrombocytopenia. Most common symptom was apnoea. Sepsis, RDS and NEC had significantly contributed to mortality. Most common cause of death was sepsis followed by RDS and NEC.Conclusions: Neonatal thrombocytopenia is a treatable and reversible condition. Hence, it is important to identify neonates at risk and initiate transfusion therapy to prevent severe bleeding and potentially significant morbidity. Anaemia and PROM were the commonest maternal risk factors. Therefore, author recommended that babies born to mothers with these risk factors should be closely monitored for thrombocytopenia.

Spinal TB: Impact of Research Evidence on Clinical Practice

The evidence generated while treating the patients is the key for growth of science. Finding answers to series of research questions spread over many years may change the clinical practice. This presentation is based on 25 research questions, 44 publications while treating 3300 patients over last 28 years ( 1990-2017) which has substantially changed the objective of treatment in spinal tuberculosis (TB) from healing of lesion with sequelae of spinal deformity and paraplegia to achieving healed status with near normal spine. Three cases of late-onset paraplegia were evaluated (1990) by newly introduced MRI. The syringohydromyelia and severe cord atrophy were attributed as the cause of paraplegia. We conducted a series of prospective studies to define and correlate MRI observations on spinal cord in paraplegia and followed the treatment outcomes. The cord edema, myelomalacia, cord atrophy and syringomyelia were observed in cases with neural complications. The patients with cord edema and liquid compression are predictor for neural recovery, while dry lesions and myelomalacia for poor neural recovery. The mild cord atrophy was consistent with neural recovery while severe cord atrophy with sequalae of neural deficit. Upto 76% canal encroachment was found compatible with intact neural state. Spinal deformity in TB spine is better prevented than treated. The contagious vertebral body disease with intact disc spaces, subperiosteal and paravertebral, septate abscesses, intra-osseous and intraspinal abscesses are considered features of spinal TB and resolution of abscess and fatty replacement is characteristic of healing. The clinicoradiological predictors for diagnosing spinal TB in predestructive disease were defined. Only 35% patients achieved healed status on MRI by DOTS regimen at 8 months, Hence, it is unscientific to stop antitubercular treatment (ATT) at fixed time schedule. The criteria to suspect multi-drug resistant (MDR)-TB and guide to treatment were defined. Residual Kyphotic deformity in spine TB produces severe proximal/distal degeneration of spine and/or late-onset paraplegia. We correlated the final kyphosis with initial vertebral body (VB) loss, where 1.5 VB height loss will produce 600 spinal deformity or more, hence surgical correction of spinal deformity is indicated. The surgical steps of kyphotic deformity correction are: anterior corpectomy, posterior column shortening, instrumented stabilization, anterior gap grafting and posterior fusion in a single stage and sequentially. The surgical incision of costo-transversectomy was modified so that kyphosis correction and posterior Hartshill instrumentation can be performed simultaneously. The retroperitoneal extrapleural approach for dorsolumbar spine was described. Meta-analysis of spinal instrumentation in TB spine established the lack of defined indication of instrumented stabilisation. Panvertebral/ long segment disease,

Langerhans cell histiocytosis of the scapula - diagnosis & treatment options / Histiocitose de células de langerhans da escápula - diagnóstico e opções de tratamento / Histiocitosis de células de langerhans de la escápula - diagnóstico y opciones de tratamiento

ABSTRACT Langerhans cell histiocytosis (LCH) is characterised by an abnormal histiocytic accumulation in tissues such as the lung, spleen, bone marrow, skin, central nervous system, liver and lymph nodes, causing focal or systemic effects. No specific clinical & radiographic presentation of LCH is described in literature. This poses a diagnostic dilemma for surgeons. The scapula is the site of 3% of bone tumours, while for LCH it is the least common site. In a 10-year-old boy with isolated lesion of the scapula with no other systemic involvement, and no specific finding in MRI or CT scan of scapula, diagnosis was confirmed on biopsy. Division into single and multi-system disease is paramount in treatment, given that it is a single system disease. The patient improved clinically on follow-up of 2 years. The scapula is one of the rarest site of LCH, and because various lesions mimic each other, a biopsy is always required, with immunohistochemistry for CD68 & S-100. This was only a single system disease, so conservative management was performed, and the patent improved clinically.

RESUMO A histiocitose de células de Langerhans (HCL) caracteriza-se por acúmulo anormal de histiócitos em tecidos como pulmão, baço, medula óssea, pele, sistema nervoso central, fígado e linfonodos, causando efeitos focais ou sistêmicos. Nenhuma apresentação clínica e radiográfica específica da HCL está descrita na literatura. Isso impõe um dilema diagnóstico para os cirurgiões. A escápula é o local de 3% dos tumores ósseos, ao passo que é o lugar menos comum para a HCL. Em um menino de 10 anos de idade, com lesão isolada na escápula e sem outro envolvimento sistêmico, sem achados específicos na RM ou na TC da escápula, o diagnóstico foi confirmado pela biópsia. A divisão entre doença isolada e de múltiplos sistemas é fundamental para o tratamento, considerando-se que este caso é uma doença de um só sistema. O paciente teve melhora clínica no acompanhamento de dois anos. A escápula é um dos locais mais raros de ocorrência da HCL, e como as lesões mimetizam umas às outras, sempre é preciso realizar biópsia por imuno-histoquímica para CD68 e S-100. Esta doença atingiu apenas um sistema, levando ao tratamento conservador e o paciente apresentou melhora clínica.

RESUMEN La histiocitosis de células de Langerhans (HCL) se caracteriza por la acumulación anormal de histiocitos en tejidos como pulmón, bazo, médula ósea, piel, sistema nervioso central, hígado y linfonodos, causando efectos focales o sistémicos. Ninguna presentación clínica y radiográfica específica de la HCL está descrita en la literatura. Eso impone un dilema diagnóstico para los cirujanos. La escápula es el local de 3% de los tumores óseos, al paso que es el lugar menos común para la HCL. En un niño de 10 años de edad, con lesión aislada en la escápula y sin otro compromiso sistémico, sin hallazgos específicos en la RM o en la TC de la escápula, el diagnóstico fue confirmado por la biopsia. La división entre enfermedad aislada y de múltiples sistemas es fundamental para el tratamiento, considerándose que este caso es una enfermedad de un único sistema. El paciente tuvo mejora clínica en el acompañamiento de dos años. La escápula es uno de los locales más raros de ocurrencia de la HCL, y como las lesiones mimetizan unas a otras, siempre es preciso realizar biopsia por inmunohistoquímica para CD68 y S-100. Esta enfermedad alcanzó a sólo un sistema, llevando al tratamiento conservador y el paciente presentó mejora clínica.

Transposition of Great Arteries with Intramural Coronary Artery: Experience with a Modified Surgical Technique

Abstract Objective: Transposition of the great arteries is a common congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation. Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text. Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730). Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons' armamentarium.

Clinical profile & outcome of H1N1 infected pregnant women in a tertiary care teaching hospital of northern India.

Background & objectives: H1N1 influenza is a recognized cause of febrile respiratory infection worldwide. There are not many studies to show its impact on pregnancy. In the present study we aimed to assess clinical characteristics, obstetric and perinatal outcome of pregnant women with H1N1 infection. Methods: A retrospective observational study was conducted at a tertiary care teaching hospital in New Delhi, India. A total of 24 pregnant women microbiologically positive for H1N1 were included. Maternal characteristics and outcome were recorded. Perinatal outcome which was defined as presence of any of the indicators such as abortion, preterm delivery, intrauterine death and neo natal death was noted. Results: The mean age of the study group was 25.2 ± 3 yr with a mean gestational age of 34.9 ± 4.6 wk. Six patients (25%) had associated co-morbidities. Nine patients (37.5%) presented within 48 h of onset of symptoms and 15 (62.5%) reported after 48 h. In 17 (70.83%) patients treatment was delayed by >48 h. ICU admission was needed in 20.8 per cent patients and mortality rates was 8.3 per cent. There were seven cases of adverse perinatal outcome. Interpretation & conclusions: The presenting symptoms of pregnant women with H1N1 were similar to that of general population. Acquiring infection in late trimester, late initiation of antiviral treatment and presence of co-morbid illness were high risk factors for developing critical illness. Pregnant women with suspected H1N1 influenza should be started on antiviral therapy at the earliest. This is likely to help reduce the ICU admission rates and mortalities in this group of women.

Evaluation of asymptomatic bacteriuria in antenatal women at C. U. Shah Medical College & Hospital, Surendranagar, Gujarat.

Background: Asymptomatic bacteriuria (ASB) refers to the presence of a bacterial isolate in urine culture in an asymptomatic person. Pregnant women with ASB are more likely to develop acute pyelonephritis in later pregnancy, postpartum urinary tract infection, hypertensive disease of pregnancy, anaemia, chronic renal failure, prematurity, low birth weight babies and prenatal death if untreated. The incidence of these can be reduced by treating ASB during pregnancy. Aims & Objective: To study the incidence of asymptomatic Bacteriuria in pregnancy. Material and Methods: Approximate 20 ml of clean catch midstream urine samples were obtained from 100 pregnant women attending the Obstetric Outpatient Department. Samples were processed as per standard guidelines. Results: Microscopic analysis of urine showed pus cells in 5 (45.45%) and Gram's stain smear showed bacteria in 9 (81.81%). Urine culture showed ASB in 11 (11%) pregnant women. Escherichia coli were found in 6 (54.55%), Klebsiella pneumoniae 3 (27.27%), Enterococcus sp. in 1 (9.09%) and Staphylococcus aureus in 1 (9.09%). Antibiotic sensitivity testing showed that all isolates were sensitive to all the antibiotics. Conclusion: Incidence of asymptomatic bacteriuria was 11% in 100 pregnant women. Microscopic analysis of all 11 urine culture positive samples showed pus cells in 5 (45.45%) and Gram's stain smear showed bacteria in 9 (81.81%). The most common bacterial isolate was Escherichia coli (54.54%), followed by Klebsiella pneumoniae (27.27%), Staphylococcus aureus (9.09%) and Enterococcus sp. (9.09%). Urine culture is necessary for screening pregnant women.

Seroprevalence of hepatitis D virus in patients with hepatitis B virus-related liver diseases.

BACKGROUND AND OBJECTIVE: Several reports indicated a declining trend in the occurrence of hepatitis D virus (HDV) infection in some geographical areas. However, no study has been conducted in India to evaluate whether a similar epidemiological change is occurring in this part of the world. The present study was undertaken to evaluate the seroprevalence of HDV in patients with hepatitis B virus (HBV) related liver diseases attending a Government hospital in New Delhi, and to assess any change in its epidemiology by comparing the results with seroprevalence figures reported in the past. METHODS: A total of 123 patients with HBV-related liver diseases comprising 32 cases of acute viral hepatitis (AVH), 5 of fulminant hepatic failure (FHF), 37 of chronic hepatitis (CH), 46 of cirrhosis and 3 of hepatocellular carcinoma (HCC). All patients were evaluated for the presence of delta antibodies using commercially available ELISA kits. Both IgM and IgG anti-delta assays were performed to differentiate between active and convalescent infection. RESULTS: The mean age of the patients was 35.6 +/- 3.3 yr with a male : female ratio of 11:5. Of the 123 patients, serological evidence of delta virus infection was seen in 13 subjects (10.6%); 9 (7.3%) had evidence of past infection (IgG positive, IgM negative) and the remaining 4 (3.3%) recent infection (IgM anti-delta antibody positive). Evidence of HDV infection in acute viral hepatitis, fulminant hepatitis, chronic hepatitis, cirrhosis and hepatocellular carcinoma groups was found in 3.1, 20, 8.1, 15.2 and 33.3 patients, respectively. INTERPRETATION AND CONCLUSION: Our results suggest that delta infection may not be very common in Indian patients with HBV-related liver diseases. It is also possible that HDV epidemiology in this part of the world may be undergoing a transition towards decreasing prevalence.

Non-familial juvenile polyposis with histological evidence of adenomatous transformation.

A 14-year-old male presented with abdominal pain, diarrhoea and a sensation of something prolapsing through the anus during defecation, and was found to have diffuse colonic polyposis. There was no evidence of mucocutaneous hyperpigmentation and family history was negative, suggesting a diagnosis of non-familial juvenile polyposis. Histological analysis of multiple endoscopic biopsies showed features typical of juvenile or retention type (hamartomatous) lesions: dilated cystic glands lined by mucocus-secreting epithelium and prominent, inflamed and congested lamina propria. However, admixed with these features, focal areas of atypical adenomatous changes were recognized. Even the intervening normal-looking colonic mucosa showed some dysplastic changes. These findings indicate that hamartomatous and atypical adenomatous epithelial changes can co exist in non-familial juvenile polyposis and the latter may confer a risk of malignant transformation in this otherwise non-neoplastic disease.

Cronkhite-Canada syndrome with adenomatous and carcinomatous transformation of colonic polyp.

We describe a 70-year-old woman who presented with watery diarrhea and was found to have gastric and colonic polyposis, cutaneous hyperpigmentation, alopecia and onychodystrophy (Cronkhite-Canada syndrome). Histology of a polyp from the stomach showed features of juvenile or retention type (hamartomatous) polyp. One colonic polyp revealed features of tubular adenoma, with moderate dysplasia. Another large pedunculated colonic polyp showed a tubulovillous adenoma with a focus of well-differentiated adenocarcinoma confined to the submucosa of the stalk. Adenomatous and carcinomatous epithelial changes can occur in Cronkhite-Canada syndrome.

Massive hepatomegaly: a presenting manifestation of multiple myeloma.

We report a 50-year-old woman presenting with isolated massive hepatomegaly. Liver histology showed dilated sinusoids within which some atypical cells, probably of hematopoeitic origin, were identified. Bone marrow was densely packed with similar atypical cells with high nucleo-cytoplasmic ratio, which tested positive for plasma cell markers. Plasma protein electrophoresis showed a distinct M spike in the gamma globulin fraction and skeletal survey revealed multiple lytic lesions in the skull and pelvic bones. Thus, a final diagnosis of multiple myeloma was made. The patient has received six cycles of chemotherapy and is doing well.