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Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the ‘moderately polluted’ south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study providessupport for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.
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Background & objectives: Data from the National Clinical Registry for COVID-19 (NCRC) were analyzed with an aim to describe the clinical characteristics, course and outcomes of patients hospitalized with COVID-19 in the third wave of the pandemic and compare them with patients admitted earlier. Methods: The NCRC, launched in September 2020, is a multicentre observational initiative, which provided the platform for the current investigation. Demographic, clinical, treatment and outcome data of hospitalized COVID-19 patients were captured in an electronic data portal from 38 hospitals across India. Patients enrolled during December 16, 2021 to January 17, 2022 were considered representative of the third wave of COVID-19 and compared with those registered during November 15 to December 15, 2021, representative of the tail end of the second wave. Results: Between November 15, 2021 and January 17, 2022, 3230 patients were recruited in NCRC. Patients admitted in the third wave were significantly younger than those admitted earlier (46.7±20.5 vs. 54.6±18 yr). The patients admitted in the third wave had a lower requirement of drugs including steroids, interleukin (IL)-6 inhibitors and remdesivir as well as lower oxygen supplementation and mechanical ventilation. They had improved hospital outcomes with significantly lower in-hospital mortality (11.2 vs. 15.1%). The outcomes were better among the fully vaccinated when compared to the unvaccinated or partially vaccinated.Interpretation & conclusions: The pattern of illness and outcomes were observed to be different in the third wave compared to the last wave. Hospitalized patients were younger with fewer comorbidities, decreased symptoms and improved outcomes, with fully vaccinated patients faring better than the unvaccinated and partially vaccinated ones.
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Objectives: To evaluate association between total IgE levels and wheezing in preschoolchildren from India. Methods: Datawere collected in a prospective birth cohort study relatedto wheezing till three years of age. Total IgE was measured at enrolment, at one year and twoyears of age and correlated with wheezing episodes. Results: A total of310 (167 boys)children were enrolled. Total IgE levels increased with age (P<0.001). Overall, 101 (32.6%)children had 182 episodes of wheezing. The median (IQR) total IgE levels in children withwheezing and without wheezing were similar at one year [42.1 (12.7, 93.5) vs 41.9 (17.1,96.7) kU/L; P=0.39] and two years of age [62.8 (32.4, 212.0) vs 75 (25.8, 173.0) kU/L,P=0.92). Conclusion: Total IgE levels increased with age and were not different in preschoolchildren with and without wheezing.
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Background: Impulse oscillometry is an effort-independenttechnique of assessment of airway resistance and reactance, andcan be performed in children unable to complete spirometry.Objective: To evaluate the utility of impulse oscillometry andspirometry for assessing asthma control in children.Study design: Prospective cohort study.Participants: Children aged 5-15 years, with mild to severepersistent asthma.Intervention: On each 3-monthly follow-up visit, clinicalassessment, classification of control of asthma, impulseoscillometry and spirometry were performed.Outcome: Utility of impulse oscillometry parameters [impedance(Z5), resistance (R5), reactance (X5) at 5 Hz, and R5-20(resistance at 20Hz -5Hz) (% predicted), and area of reactance(AX, actual values)] and FEV1 (% predicted) to discriminatebetween controlled and uncontrolled asthma was assessed byreceiver operating characteristic (ROC) curve. Association ofFEV1 and impulse oscillometry parameters over time withcontrolled asthma was evaluated by generalized estimatingequation model.Results: Number of visits in 256 children [mean (SD) age, 100(41.6) mo; boys: 198 (77.3%)], where both impulse oscillometryand spirometry were performed was 2616; symptoms werecontrolled in 48.9% visits. Area under the curve fordiscrimination between controlled and uncontrolled asthma byFEV1, AX, R5-20, Z5, R5, and X5 were 0.58, 0.55, 0.55, 0.52,0.52 and 0.52, respectively. FEV1 [OR (95% CI): 1.02 (1.01-1.03)]and AX [OR (95% CI): 0.88 (0.81-0.97)] measured over theduration of follow-up were significantly associated withcontrolled asthma.Conclusion: Spirometry and impulse oscillometry parametersare comparable in ascertaining controlled asthma. Impulseoscillometry being less effort-dependent may be performed formonitoring control of childhood asthma, especially in youngerchildren.
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Objective: To develop a normal reference range of Infantpulmonary function test (IPFT) indices for Indian children.Design: Prospective birth cohort study.Setting: Division of Pediatric Pulmonology of a tertiary-careinstitute in India from August 2012 to March 2017.Participants: All neonates born at the institute during the studyperiod were screened for eligibility.Measurement: IPFT at baseline and every 6-month until 36-months of age.Main Outcome Measure(s): Tidal breathing flow-volume loop(TBFVL), Rapid thoracoabdominal compression (RTC), andRaised volume RTC (RVRTC) indices at baseline and follow-up.Results: 310 newborns were enrolled in the cohort; 281 of them(169 male) had completed 36-months of follow-up at the end ofthe study period. There was no influence of gender on thebaseline IPFT indices. Tidal volume per unit body weight (VT/kg)significantly increased from baseline to 36 months of age(P<0.001) while the peak ratio (tPTEF/tE) initially decreased in first18-months of age (P<0.001), after that returned to the baselinevalue by 36 months of age. RTC indices did not changesignificantly from baseline values. In RVRTC, the ratio of forcedexpiratory volume in 0.5s to forced vital capacity (FEV0.5/FVC)was significantly decreased from baseline to 36 months of age(P=0.002).Conclusions: Normal values for various IPFT indices for TBFVL,RTC, and RVRTC from neonates to the age of 36-month areprovided. These data may be used as normative data for healthyneonates and children of Indian origin
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Objectives: To document clinical features and outcome of children with sarcoidosis.Methods: Case records of 18 children (mean (SD) age 9 (2.2) years) diagnosed withsarcoidosis between 2006 and 2016 were reviewed. All children were followed up every 2-3months and monitored for clinical and laboratory parameters. Their treatment and outcomewere recorded. Results: Clinical features at the time of diagnosis were fever (83%), uveitis(50%), difficulty in breathing (44%), hepatosplenomegaly, weight loss, arthritis and peripheraladenopathy. Imaging findings included: hilar adenopathy (94%), abdominal nodes (50%) andpulmonary infiltrates (44%). All children were treated with steroids (range 6-12 months) andweekly low dose oral methotrexate. All patients showed significant improvement over a mean(SD) duration of follow-up of 3.1 (0.9) years, as assessed by resolution of clinical symptoms,and improvement in spirometry parameters, erythrocyte sedimentation rate, and serumangiotensin converting enzyme levels. Conclusions: Children with sarcoidosis seem torespond well to systemic steroids and low dose methotrexate. Delayed diagnosis and ocularinvolvement are probably associated with poor outcome.
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Objective: To evaluate utility of XpertMTB/RIF in bronchoalveolar lavage fluid in childrenwith probable pulmonary tuberculosis. Methods: Children with probable pulmonarytuberculosis with negative smear and Xpert on induced sputum/gastric aspirate weresubjected to bronchoalveolar lavage (BAL) for Xpert assay and mycobacterial liquid culture.Data of children <14 y undergoing bronchoscopy for suspected MDR-TB (n=12) were alsoanalyzed. The sensitivity of Xpert in BAL fluid for diagnosis of probable and confirmedpulmonary tuberculosis was calculated with clinico-radiological diagnosis and culture as goldstandards, respectively. Results: Of 41 enrolled children, 24 (58.5%) had Xpert positive inBAL fluid and 11 (26.8%) had culture confirmed tuberculosis (BAL fluid;10; sputum,1). Thesensitivity of Xpert in BAL fluid among probable and culture confirmed tuberculosis caseswas 58.5% (24/41) and 81.8% (9/11), respectively. Conclusion: Xpert in bronchoalveolarlavage fluid has good sensitivity in both probable and confirmed pulmonary tuberculosis inchildren
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Background & objectives: Deficiency of vitamin D, an immunomodulator agent, is associated with increased susceptibility to tuberculosis in adults, but only limited studies are available in the paediatric age group, especially regarding association of vitamin D with type and outcome of tuberculosis. We conducted this study to determine the baseline 25-hydroxy vitamin D levels in children suffering from intrathoracic tuberculosis and its association with type and outcome of tuberculosis. Methods: Children with intrathoracic tuberculosis, diagnosed on the basis of clinico-radiological criteria, were enrolled as part of a randomized controlled trial on micronutrient supplementation in paediatric tuberculosis patients. Levels of 25-hydroxy vitamin D were measured in serum samples collected prior to starting antitubercular therapy by chemiluminescent immunoassay technology. Results: Two hundred sixty six children (mean age of 106.9 ± 43.7 months; 57.1% girls) were enrolled. Chest X-ray was suggestive of primary pulmonary complex, progressive disease and pleural effusion in 81 (30.5%), 149 (56%) and 36 (13.5%) subjects, respectively. Median serum 25-hydroxy vitamin D level was 8 ng/ml (IQR 5, 12). One hundred and eighty six (69.9%) children were vitamin D deficient (serum 25-hydroxy vitamin D <12 ng/ml), 55 (20.7%) were insufficient (12 to <20 ng/ml) and 25 (9.4%) were vitamin D sufficient (≥ 20 ng/ml). lLevels of 25-hydroxy vitamin D were similar in all three types of intrathoracic tuberculosis, and in microbiologically confirmed and probable cases. Levels of 25-hydroxy vitamin D did not significantly affect outcome of the disease. Children who were deficient or insufficient were less likely to convert (become smear/culture negative) at two months as compared to those who were 25-hydroxy vitamin D sufficient (p<0.05). Interpretation & conclusions: Majority of Indian children with newly diagnosed intrathoracic tuberculosis were deficient in vitamin D. Type of disease or outcome was not affected by 25-hydroxy vitamin D levels in these children. However, children who did not demonstrate sputum conversion after intensive phase of antitubercular therapy had lower baseline 25-hydroxy vitamin D levels as compared to those who did.
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Objective: To determine the trough and two hour plasma levels of nevirapine, stavudine, and lamivudine when administered in fixed dose combinations (FDC). Design: Cross sectional Setting: Tertiary care hospital in Northern India. Participants: 79 HIV-infected children receiving antiretroviral therapy with FDCs for more than month. Intervention: Two-point sampling (0 and 2 hours after the morning dose). Outcome measures: Plasma concentrations of all three drugs were simultaneously assayed by liquid chromatography/mass spectroscopy. Results: Majority (77%) of children were receiving fixed dose combination of stavudine, lamivudine, nevirapine in the ratio of 6:30:50mg. The median (IQR) trough and 2-hour plasma levels (µg/mL) of nevirapine, stavudine and lamivudine were 5.2 (4.0, 6.3) and 7.9 (6.0, 9.7); 0.1 (0.06, 0.16) and 1.1 (0.59, 1.6); 0.1 (0.02, 0.2) and 2.5 (1.4, 3.1), respectively. Very few children had sub-therapeutic plasma drug levels of stavudine (2.5%), lamivudine (7.6%) and nevirapine (10%). Inadequate viral suppression at 6 months follow up was significantly associated with initial high viral load, low CD4 percentage at the time of enrolment in study, and lower doses of lamivudine and stavudine. Conclusion: The currently available generic pediatric fixed dose antiretroviral combinations in India provide adequate drug exposure in majority of children.
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Objective: To determine whether fractional exhaled nitric oxide (FENO) has a utility as a diagnostic or predictive maker in acute exacerbations of asthma in children. Design: Analysis of data collected in a pediatric asthma cohort. Setting: Pediatric Chest Clinic of a tertiary care hospital Methods: A cohort of children with asthma was followed up every 3 months in addition to any acute exacerbation visits. Pulmonary function tests (PFT) and FENO were obtained at all visits. We compared the FENO values during acute exacerbations with those at baseline and those during the follow up. Results: 243 asthmatic children were enrolled from August 2009 to December 2011 [mean (SD) follow up - 434 (227) days]. FENO during acute exacerbations was not different from FENO during follow up; however, FENO was significantly higher than personal best FENO during follow up (P < 0.0001). FENO during acute exacerbation did not correlate with the severity of acute exacerbation (P=0.29). The receiver operating characteristics curve for FENO as a marker for acute exacerbation had an area under the curve of 0.59. Cut-off of 20 ppb had a poor sensitivity (44%) and specificity (68.7%) for acute exacerbation. Conclusions: FENO levels during acute exacerbation increase from their personal best levels. However, no particular cut off could be identified that could help in either diagnosing acute exacerbation or predicting its severity.
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Objective: To determine the prevalence of sensitization to common aeroallergens in asthmatic children and study the differences in characteristics of atopics and non atopics. Design: Analysis of data from a prospective cohort study. Setting: Pediatric Chest Clinic of tertiary care center in Northern India Patients: Asthmatic children from 5-18 year of age. Main outcome measures: Prevalence of sensitization to common aeroallergens. Results: Skin prick testing (SPT) was performed on 180 children above 5 years of age, with a mean (SD) age of 111.4 (34.2) months. 100 children (55.6%) were sensitized to at least one aeroallergen, suggesting atopy; 68 (37.8%) were sensitized to more than one allergen. 36.7% children were sensitized to housefly antigen; 31.1% to rice grain dust, 18.3% to cockroach, and 7.8% to house dust mite antigens. Atopic children had significantly higher median FENO during follow up than nonatopic children (17.5 ppb vs 13 ppb, P=0.002). There was a positive correlation between age and the number of allergens that an individual was sensitized to (r= 0.21; P=0.0049). Conclusions: More than half of asthmatic children in our cohort had sensitization to one or more aeroallergens suggesting atopy; sensitization was most commonly seen to housefly antigen and rice grain dust. Atopic children had significantly higher FENO measurements during follow up as compared to non-atopic children.
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Objective. To assess the quality of life (QOL) and the psychosocial problems of HIV infected children. Methods. The present study was a comparative, cross-sectional survey conducted in the clinic of a tertiary care hospital in north India from July- December 2007. Children suffering from cystic fibrosis (CF) were chosen as a comparison group. Children ≥ 6 yr of age with HIV infection or Cystic Fibrosis, with no acute illness at the time of survey were included in the study. Quality of life of the enrolled children was assessed by using the Pediatric Quality of Life InventoryTM (PedsQLTM). Pediatric Symptom Checklist (PSC) was used for assessing the psychosocial problems in the enrolled children. Results. Forty one HIV infected and 30 children with cystic fibrosis were enrolled. According to child self -report in the PedsQLTM 4.0, the difference of perceived physical health status between the two study groups was statistically significant (p=0.04), with HIV infected children demonstrating a better QOL in this domain. A significantly greater number of children with cystic fibrosis (8/30 or 26.67%) suffered from psychosocial problems as compared to HIV children (3/41 or 7.32%) [p=0.026]. Conclusions. The quality of life and psychosocial functioning is reasonably good in children with HIV infection. Thus, we should strive to maintain and optimize the overall quality of life of these children so that they can have a productive and meaningful future.
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Actividades Cotidianas , Adolescente , Niño , Estudios Transversales , Fibrosis Quística/psicología , Femenino , Infecciones por VIH/psicología , Hospitales Universitarios , Humanos , India , Masculino , Calidad de Vida/psicología , Encuestas y CuestionariosRESUMEN
Background. Clinicians and associated health professionals charged with prescribing antiretroviral therapy (ART) deal with continuously evolving new drugs and combinations. To meet the needs of clinicians in India for ongoing education in this field, continuing medical education (CME) programmes on ART for HIV/AIDS were developed, conducted, evaluated and revised. Over a 2-year period, 2005–2007, 3 CME programmes for ART were conducted for physicians and a fourth (predominantly) for paediatricians. Methods. Both 1- and 2-day CME programmes on various aspects of ART were held on weekends for professionals treating patients with AIDS in Delhi and adjacent states. Topics included characteristics of ART drugs, their dosages, monitoring and toxicity management, adherence, complications of therapy, dealing with treatment failure and HIV co-infections. These topics were addressed in lectures and group discussions and via case presentations. Programmes were evaluated by anonymous response to questionnaires, by a 1-year follow up of participants and by informal discussions with participants and faculty. Detailed analyses and a recommended format for these programmes are presented. Results. The CMEs were attended primarily by clinicians (physicians and paediatricians). Nurses, laboratory scientists, and others involved in the treatment of AIDS also attended the programmes. An interactive workshop format was evolved with substantial time devoted to discussions and case analyses. Oneday programmes such as the one included here can be comprehensive and effective. The educational needs of healthcare professionals who provide care and support to patients receiving ART were similar to those of the prescribing doctors. Because of new drugs being made available and with continued clinical experience, updated programme content was required each year. Participants preferred case-based interactive discussions rather than didactic lectures. Participants suggested that there should be more time for discussion after each talk. Conclusion. Annual CME programmes focused on ART are required to meet the professional needs of clinicians in India for providing quality care management to patients with AIDS.
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Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Técnicos Medios en Salud , Educación Médica Continua , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , India , Masculino , Evaluación de NecesidadesRESUMEN
Idiopathic CD4+ T lymphocytopenia (ICL) is an unusual immune defect in which there is an unexplained deficit of CD4+ T cells, leading to serious opportunistic infections. In view of the rarity of this clinical entity, we report two cases of ICL who presented with low CD4+ count or percentage and various opportunistic infections like candida, cytomegalovirus, Mycobacterium tuberculosis.