Risk Stratification Using Appendicitis Inflammatory Response Score, A Useful Tool To Reduce Negative Appendicectomy Rate : Our Experience

Background: Acute appendicitis is mostly considered a clinical diagnosis and many surgeons resort to clinical judgement for deciding its management. Such cases often pose a diagnostic dilemma and result in significant negative exploration rates. Appendicitis Inflammatory Response (AIR) score, designed in 2008, is a validated clinical scoring system which has outperformed the well-known Alvarado scoring system. This study evaluates the risk stratification of patients as per AIR scores, correlation with the post-op histopathological examination (HPE) diagnosis to calculate the negative appendicectomy rate and to evaluate the diagnostic performance of this scoring system. Method:This is a prospective observational study carried out between Nov 2016 and May 2018, on 150 cases of acute appendicitis that underwent surgical management. Result: This study data revealed a negative appendicectomy rate of 9.33 %. Statistical analysis showed that scores of 9 - 12 has great accuracy for diagnosis, with a specificity of 100 % and positive predictive value of 1.0 whereas low scores of 0-4 potentially identify cases who do not require surgery. Conclusion:The AIR score is an accurate diagnostic tool when a score of 9 is taken as cut-off. Management algorithms based on AIR score have the potential of reducing negative appendicectomy rate by correct identification of those who don't require surgery.

Electrolyte Changes in the Term Neonates Following Phototherapy in Neonatal Hyperbilirubinemia

Hyperbilirubinemia is one of the most prevalent problems in neonates. Jaundice is observed during first week of life in approximately 60% of term neonates and 80% of preterm neonates. Phototherapy is the most common therapeutic modality used in the treatment of uncomplicated neonatal hyperbilirubinemia. Objective: To study electrolyte (Ca, Na, K, Cl) changes in the term neonates following phototherapy in neonatal hyperbilirubinemia. Methods: This study was performed on 100 term neonates (65 males, 35 females) admitted to the Department of Pediatrics, Bebe Nanki Mother and Child Care Centre, Government Medical College, Amritsar, Punjab with unconjugated hyperbilirubinemia and were managed with phototherapy. These neonates were completely normal on physical examination. Electrolytes were checked at 0 hr (at the time of admission) and after 48 hours of phototherapy or at discontinuation of phototherapy (second sample) whichever was earlier. The first sample was considered as control. Results: After phototherapy, among electrolytes (Ca, Na, K ,Cl) there was significant fall in serum calcium (ionized) level. 16 neonates developed hypocalcemia after 48 hr or less of phototherapy and 11 neonates developed hypocalcemia after 48 hr or up to 96 hr of phototherapy. The difference between pre and post phototherapy serum calcium (ionized) levels was found to be statistically significant (p <0.005). Of the 27 term neonates who developed hypocalcemia, 7 (26%) developed jitteriness and none of them developed irritability, seizures and aponea. No statistically significant fall/rise in levels of Na, K, Cl were observed in term neonates after phototherapy. The incidence of potassium, sodium and chloride changes following phototherapy was found to be nonsignificant irrespective of gestational age, birth weight and duration of phototherapy. Conclusion: The study concluded that among electrolytes (Ca, Na, K, Cl), phototherapy induced hypocalcemia is a significant problem. Thus calcium supplementation should be considered.

A Study of Hyponatremia in Lower Respiratory Infections in Children Aged 2months to 5 Years

We studied serum sodium levels within 2 hours of admission of 100 children aged 2months to 5 years admitted with diagnosis of lower respiratory infections(pneumonia,bronchiolitis, bronchitis, empyema and WALRI). Methods: In our study out of these 100 cases 33(33%) cases were having hyponatremia (s.sodium<135mEq/L) &0ut of33(33%) cases 17(51.5%) cases had mild hyponatremia i.e. s.sodium 131-134mEq/L, 14(42.5%) cases had moderate hyponatremia i.e. s.sodium 126-130mEq/L & 2(6%)cases had severe hyponatremia i.e. s.sodium <125mEq/L. These Children with hyponatremia were evaluated for plasma osmolality, urinary sodium and osmolality on day of admission and after appropriate fluid therapy. Results: Out of these 33 cases, the probable cause of hyponatremia was the syndrome of inappropriate secretion of antidiuretic hormone in 27(81.8%) cases (as suggested by their plasma osmolality,urinary sodium and urine osmolality). Symptoms and signs indicative of severe LRIs were about one and a half times more frequent and the mean duration of hospital stay was 49.2% longer in children with hyponatremia than with isonatremia. Two children (2%) with severe hyponatremia had complications in the form of convulsions associated with transitory altered sensorium for 2-3 days. The recovery from hyponatremia with timely intervention showed a good improvement in clinical symptomology of respiratory distress and there was no mortality in the studied cases. Conclusion: Thus it is concluded that,presence of hyponatremia in LRI’s increases the morbidity of these patients in the form of prolonged hospital stay and occurrence of complications like seizures followed by deranged sensorium in some cases.

To Study Nutritional Factors and Postnatal Growth as Predictors of Retinopathy of Prematurity in Neonates Weighing <1750g and/ or Gestation <34 Weeks

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the developing retinal vessels of premature infants. ROP remains one of the leading causes of childhood blindness worldwide. India and other developing countries are facing the third epidemic of ROP. Various risk factors for development of ROP include low gestational age, low birth weight, hyaline membrane disease, sepsis, shock, prolonged oxygen therapy, poor nutrition and weight gain and blood transfusions. Objective: To study nutritional factors and postnatal growth as predictors of ROP in neonates weighing <1750g and/ gestation <34 weeks. Methods: It is a prospective observational study conducted over one year (May 2017 to April 2018) in NICU, Department of Pediatrics, Govt. Medical College Amritsar, in collaboration with Department of Ophthalmology. All antenatal, perinatal and neonatal factors along with nutritional factors and postnatal growth mointoring were recorded. Screening for ROP was done by indirect opthalmoscopy at 4 weeks of postnatal age and followed up till retinal vascularization was complete. Data was analysed using univariate and multivariate regression analysis to evaluate risk factors. Results: Out of 79 babies screened 44 were found to have ROP of which 4 required treatment. Important risk factors found significant on univariate analysis were low birth weight (p=0.023) gestational age (p=0.003), duration of i/v fluid therapy (p=0.004), day of start of feed (p=0.032), day of attainment of full feed (p=0.005), relative weight gain at 4 weeks (p=0.041) and 6 weeks of life (p=0.04). On mutivariate logistic analysis, relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor. Conclusion: Relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor for development of ROP. This result may be regarded as providing emphasis on the importance of weight gain at an earlier postnatal age.

To Study the Effect of Ursodeoxycholic Acid in Lowering Neonatal Non – Hemolytic Hyperbilirubinemia: A Randomized Control Study

Hyperbilirubinemia is a common and in most cases, a benign problem in neonates. Conventional treatment for severe indirect hyperbilirubinemia consists of phototherapy and exchange transfusion. Phototherapy, which is the main treatment modality has its own side effects and it also upsets maternal and fetal interactions. So there is a need for adjuvant therapies to decrease duration of phototherapy and hospital stay. Objective: This study was planned to assess the role of UDCA in decreasing the duration of phototherapy in neonatal hyperbilirubinemia. Methods: Study setting: Pediatrics department, Bebe Nanki Mother & Child Care Centre, GMC Amritsar. Participants: 100 newborns with bilirubin levels in phototherapy range. Study design: Double blind, placebo controlled study. Participants were divided into two groups and UDCA (10mg/kg/d) and microcrystalline cellulose were given to group A and group B respectively. Outcome variables: Rate of fall of bilirubin levels in both the groups and total duration of phototherapy needed in both groups. Results: Mean duration of phototherapy was 36.26±8.41 hours in group A and 38.94±9.86 hours in group B. P value was 0.147 that is statistically not significant. Level of fall of bilirubin in both groups at 12hrly intervals were also compared and difference was not statistically significant. Conclusion: UDCA administration to the neonates receiving phototherapy does not hasten the fall in bilirubin levels and does not reduce the time of phototherapy significantly.

Hypoglycemia in Neonates More than 1500 Gram Weight with No Secondary Cause – Its Effects and Outcome

Aim: 1) To study the outcome of hypoglycemia in neonates weighing >1500gram both symptomatic and asymptomatic having exclusively hypoglycemia with no any other medical condition known to cause brain damage , till 9 months of corrected gestational age(CGA).2) To study the clinical profile of hypoglycemia in neonates weighing >1500gram. Methods: 35 neonates weighing >1500gram with hypoglycemia (<40 mg/dl), both symptomatic and asymptomatic without any other medical condition known to cause brain damage were enrolled in the study. Hypoglycemia was confirmed with venous sample laboratory value. Both neonatal and maternal history was taken in detail, clinical examination, anthropometry was done. Follow up was done at 3, 6, 9 months of CGA for assessing neurodevelopmental outcome (motor developmental quotient i.e. MoDQ and mental developmental quotient i.e. MeDQ using DASII6 i.e. development assessment scale for Indian infants) and we did anthropometry and clinical examination, ultrasonography at discharge, electroencephalogram (EEG) done in patients with seizure, Magnetic Resonance Imaging (MRI) at 3 months, Brainstem evoked response audiometry (BERA) at 6 months, vision assessment at 9 months of CGA. Appropriate statistical analysis was done to calculate results. Results: Out of 35 enrolled cases follow up was possible in 30 cases. In our study, the prevalence of abnormal neurodevelopmental outcome according to DASII6 was 53.33% (n=16) cases with abnormal MoDQ (<70%) and 56.66% (n=17) cases with abnormal MeDQ (<70%) at 3, 6, 9 months of CGA respectively. There was statistically significant difference in the mean values of MoDQ (p value 0.014, 0.011, 0.02) and mean MeDQ (p value 0.019, 0.008, 0.02) on follow up at 3, 6, 9 months of corrected gestational age respectively between symptomatic and asymptomatic hypoglycemic cases. 8 (57.14%) symptomatic cases and 6 (37.5%) asymptomatic cases had microcephaly on follow up and the difference was not statistically significant. MRI was abnormal in 10 (71.4%) symptomatic cases and 6 (37.5%) asymptomatic cases and the difference was not statistically significant. Ultrasonography was done in all cases at discharge and it was found abnormal in 2(5.7%) cases. BERA, vision assessment and EEG was normal in all cases. Conclusion: Both symptomatic and asymptomatic hypoglycemia leads to abnormal neurodevelopmental outcome but it is more poor in symptomatic neonates as compared to asymptomatic hypoglycemia.

Liquid-based cytology versus conventional cytology for evaluation of cervical Pap smears: Experience from the first 1000 split samples.

Context and Aim: Screening programs using conventional cytology conventional Pap smear (CPS) have successfully reduced cervical cancer, but newer tests like liquid-based cytology (LBC) and human papillomavirus testing might enhance screening. The main aim of the present study was to assess the diagnostic accuracy of LBC versus CPS using “split samples.” Materials and Methods: This was a prospective study comprising of 1000 consecutive cervical “split samples” over a period of 1 year. Split sample was obtained using cervex-brush. CPS was prepared from the brush and the brush head was suspended in the LBC vial and processed by SurePath™ LBC. Results: There were 4.3% unsatisfactory (U/S) cases in CPS and 1.7% in LBC; the main cause is insuffi cient cells, and excess of blood in CPS. About 25/100 (2.5%) split samples had epithelial abnormalities both in CPS and LBC (1.2%-atypical squamous cells of undetermined signifi cance; 0.4%-low grade squamous intraepithelial lesion; 0.2%-high grade squamous intraepithelial lesion; 0.5%-squamous cell carcinoma; 0.1%-atypical glandular cells favouring neoplasia; 0.2%-adenocarcinoma). Infl ammatory organisms were almost equally identifi ed in both techniques but were better seen in LBC samples. Conclusions: LBC technique leads to signifi cant reduction of U/S rate. LBC samples offered better clarity, uniform spread of smears, less time for screening and better handling of hemorrhagic and infl ammatory samples. LBC had equivalent sensitivity and specifi city to CPS.

Iron Deficiency in Indian Children with Attention Deficit Hyperactivity Disorder.

A case control study was conducted at the Child Development and Early Intervention Clinic to determine the body iron status of children with ADHD, and study the correlation between the body iron status and ADHD symptoms. Serum ferritin was measured in newly diagnosed cases with ADHD and compared with that of controls. Correlation was studied between serum ferritin levels and the severity of ADHD symptoms as determined by Conners’ Rating Scale. Serum ferritin was found to be significantly lower in children with ADHD (6.04 ± 3.85 ng/ mL) as compared to controls (48.96 ± 41.64 ng/mL, P value<0.001). There was a significant negative correlation between serum ferritin levels and oppositional subscore on Conners’ Rating Scale.