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Justification: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. Objectives: To develop a guideline for the use of probiotics in children with diarrhea. Process: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subject experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. Recommendations: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recom-mendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrheapredominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, and for prevention of recurrences and maintenance of remission in pouchitis.
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Purpose@#In children overlap of autoimmune hepatitis (AIH) and primary sclerosing cholangitis is labelled as autoimmune sclerosing cholangitis (ASC). The only prospective pediatric study showed a high prevalence of ASC by using endoscopic retrograde cholangiopancreatography. Aims of our study were to find the prevalence of ASC by using magnetic resonance cholangiography (MRC) in AIH and in non-AIH cirrhosis and to compare clinical presentation and outcome of AIH and ASC. @*Methods@#Prospectively we did MRC in 38 children with AIH (cases) and 19 disease controls (Wilson disease). Multiple biliary strictures with proximal dilatation on MRC were taken as definitive changes of ASC. Detail clinical, laboratory parameters, liver histopathology and treatment outcome were recorded. @*Results@#The median age of cases was 11.5 (3–18) years, 22 (57.9%) were girls and 28 (73.7%) were diagnosed as type 1 AIH. MRC was done in 11 children (28.9%) at the time of diagnosis and in 27 (71.1%) after a median follow-up of 2.5 (0.3–10) years. Abnormal MRC changes were seen in 14/38 (36.8%) of AIH and 8/19 (42.1%) of controls. However, definite changes of ASC were present in four (10.5%) children in AIH and none in controls. None of the clinical, laboratory, histological parameters and treatment response were significantly different between ASC and AIH groups. @*Conclusion@#The prevalence of ASC in children with AIH was just 10.5%. We suggest MRC in select group with cholestatic features, inflammatory bowel disease and in those who showed poor response to immunosuppression instead of all children with AIH.
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Purpose@#In children overlap of autoimmune hepatitis (AIH) and primary sclerosing cholangitis is labelled as autoimmune sclerosing cholangitis (ASC). The only prospective pediatric study showed a high prevalence of ASC by using endoscopic retrograde cholangiopancreatography. Aims of our study were to find the prevalence of ASC by using magnetic resonance cholangiography (MRC) in AIH and in non-AIH cirrhosis and to compare clinical presentation and outcome of AIH and ASC. @*Methods@#Prospectively we did MRC in 38 children with AIH (cases) and 19 disease controls (Wilson disease). Multiple biliary strictures with proximal dilatation on MRC were taken as definitive changes of ASC. Detail clinical, laboratory parameters, liver histopathology and treatment outcome were recorded. @*Results@#The median age of cases was 11.5 (3–18) years, 22 (57.9%) were girls and 28 (73.7%) were diagnosed as type 1 AIH. MRC was done in 11 children (28.9%) at the time of diagnosis and in 27 (71.1%) after a median follow-up of 2.5 (0.3–10) years. Abnormal MRC changes were seen in 14/38 (36.8%) of AIH and 8/19 (42.1%) of controls. However, definite changes of ASC were present in four (10.5%) children in AIH and none in controls. None of the clinical, laboratory, histological parameters and treatment response were significantly different between ASC and AIH groups. @*Conclusion@#The prevalence of ASC in children with AIH was just 10.5%. We suggest MRC in select group with cholestatic features, inflammatory bowel disease and in those who showed poor response to immunosuppression instead of all children with AIH.
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Malaria continues to be a life threatening infectious disease throughout the tropical region of the world.aminopeptidase N1 (APN1) is one of the best choices for developing new Malaria Transmission-blockingvaccines. In this study an attempt has been made to overview genome-wide identification of APN genes inAnopheles gambiae. A total of eighteen A. gambiae APN sequences were found that contain conserved HEXXHand GAMEN signature sequences, indicate that large numbers of APN isomers present in mosquitoes. MultipleAPN paralogs exist as a gene cluster may propose that huge synthesis of APNs is required for rapid digestion ofpeptides over a brief period. Gene structure study shows high sequence variations among them. Protein–proteininteractions show that APN1 is highly connected protein, supporting their role as hub with other five types ofAPNs involved in glutathione metabolism, act as hub protein and disruption of one of these proteins may affectthe whole pathway
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Justification: Management practices of functional constipation are far from satisfactory in developing countries like India; availableguidelines do not comprehensively address the problems pertinent to our country.Process: A questionnaire-based survey was conducted among selected practising pediatricians and pediatric gastroenterologists inIndia, and the respondents agreed on the need for an Indian guideline on the topic. A group of experts were invited to present thepublished literature under 12 different headings, and a consensus was developed to formulate the practice guidelines, keeping in viewthe needs in Indian children.Objective: To formulate practice guidelines for the management of childhood functional constipation that are relevant to Indian children.Recommendations: Functional constipation should be diagnosed only in the absence of red flags on history and examination. Thosewith impaction and/or retentive incontinence should be disimpacted with polyethylene glycol (hospital or home-based). Osmoticlaxatives (polyethylene glycol more than 1 year of age and lactulose/lactitol less than 1 year of age) are the first line of maintenancetherapy. Stimulant laxatives should be reserved only for rescue therapy. Combination therapies of two osmotics, two stimulants or twoclasses of laxatives are not recommended. Laxatives as maintenance therapy should be given for a prolonged period and should betapered off gradually, only after a successful outcome. Essential components of therapy for a successful outcome include counselling,dietary changes, toilet-training and regular follow-up.
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Background & objectives: Mutations in fms-like tyrosine kinase 3 (FLT3) receptor have significant role in assessing outcome in patients with acute myeloid leukaemia (AML). Data for FLT3 surface expression in relation to FLT3 internal tandem duplication (ITD) status and outcome are not available from India. The objective of the current study was to investigate adult patients with AML for FLT3 expression and FLT3 ITD mutation, and their association with long-term outcome. Methods: Total 51 consecutive de novo AML patients aged 18-60 yr were enrolled in the study. FLT3 ITD was detected by polymerase chain reaction (PCR); flowcytometry and qPCR (Taqman probe chemistry) were used for assessment of FLT3 protein and transcript, respectively. Kaplan Meier curves were obtained for survival analysis followed by log rank test. Results: FLT3 ITD was present in eight (16%) patients. Complete remission was achieved in 33 (64.6%) patients. At 57.3 months, event free survival (EFS) was 26.9±6.3 per cent, disease free survival (DFS) 52.0±9.2 per cent, and overall survival event (OS) 34.5±7.4 per cent. FLT3 surface expression was positive (>20%) by flow-cytometry in 38 (88%) of the 51 patients. FLT3 surface expression and transcripts were not associated with FLT3 ITD status. FLT3 expression was significantly associated with inferior EFS (P=0.026) and OS (P=0.018) in those who were negative for FLT3 ITD. Interpretation & conclusions: This study evaluated FLT3 ITD mutation along with FLT3 expression in AML patients, and associated with survival. Negative impact of FLT3 surface expression on survival was observed in AML patients who were FLT3 ITD negative.
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Objective: To analyze the presentation and predictors of outcome of children with galactosemia. Methods: Analysis of clinical, laboratory, microbiological profile and outcome of patients fulfilling the diagnostic criteria: i) clinical setting; ii) reduced erythrocyte Gal-1-PUT enzyme activity; and iii) unequivocal response to lactose-free diet. Results: 24 patients; median age of symptom onset and diagnosis: 10 (3-75) d and 55 (15-455) days, respectively. 71% had uncorrectable coagulopathy; 71% systemic infections; and 54% had ascites. Outcome: consisted of 87.5% survival with normalization of liver function tests at 5.5 (1-24) months follow-up. Conclusion: Despite delayed referral, high Pediatric end-stage liver disease scores and systemic infections, long-term outcome in galactosemia is rewarding. A subset of children have developmental delay.
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Oxidative stress has been shown to play a critical role in the pathogenesis of ulcerative colitis (UC). Entada pursaetha has been demonstrated to have antioxidant and anti-inflammatory effects. In this study, we investigated the effects of stem of alcoholic extract of E. pursaetha (PSE) in dextran sodium sulfate (DSS)-induced colitis in mice. The protective effect of PSE was determined at three different doses of 30, 100 and 300 mg/kg body weight by oral gavage for 7 days. Morphological (colon length and colon weight/length ratio), clinical (disease activity index) and macroscopic (damage score) features were determined using standard criteria. Lipid peroxides (determined as malonaldehyde; MDA), enzymatic (superoxide dismutase; SOD and catalase; CAT) and non- enzymatic antioxidants (reduced glutathione; GSH), nitrate and nitrite (NOx) levels and myeloperoxidase (MPO) activity in colon tissues were determined. The DSS damaged the colonic tissue, increased MPO activity, lipid peroxidation and NOx levels, reduced the antioxidant enzymes and glutathione and lowered the body weight. PSE significantly reduced the inflammation of colon and reversed the increase in MPO activity induced by DSS. It also significantly increased the SOD and catalase activities and did not elicit any effect on depleted levels of GSH in the colonic tissue. In addition, PSE also significantly decreased colonic NOx and MDA levels compared to DSS-treated mice; reduced both infiltration of inflammatory cells and the mucosal damage in colon on histopathological examination. The results suggested the protective potential of PSE in DSS-induced colitis and this might be attributed to its anti-inflammatory and antioxidant activities.
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Animales , Antioxidantes , Colitis Ulcerosa/inducido químicamente , Sulfato de Dextran/toxicidad , Fabaceae/química , Fabaceae/uso terapéutico , Ratones , Estrés Oxidativo , Extractos Vegetales/química , Extractos Vegetales/uso terapéuticoRESUMEN
The alcoholic extract of stem of E. pursaetha (PSE, 30, 100, 300 mg/kg body weight, po for 7 days) showed hepatoprotective activity against CCl4 (2 mL/kg body weight, ip)-induced hepatotoxicity. The extract exhibited a significant dose-dependent hepatoprotective effect comparable to standard drug silymarin, by preventing increase in serum levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total protein, and total bilirubin, lactate dehydrogenase; by lowering hepatic levels of malonaldehyde, nitrate-nitrite, myeloperoxidase activity; enhancing activities of antioxidant enzymes, superoxide dismutase, catalase and increasing reduced glutathione levels in liver, which suggests the antioxidant property of PSE. Histopathological studies also supported the above biochemical parameters. The results suggested that alcoholic extract of E. pursaetha possesses significant hepatoprotective activity in CCl4-induced acute hepatotoxicity in rats and this is likely to be mediated through its antioxidant activities.
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Animales , Antioxidantes/metabolismo , Tetracloruro de Carbono/toxicidad , Catalasa/metabolismo , Enfermedad Hepática Inducida por Sustancias y Drogas/tratamiento farmacológico , Enfermedad Hepática Inducida por Sustancias y Drogas/patología , Fabaceae/química , Glutatión/metabolismo , Peroxidación de Lípido/efectos de los fármacos , Hígado/efectos de los fármacos , Hígado/patología , Extractos Vegetales/administración & dosificación , Extractos Vegetales/química , Ratas , Superóxido Dismutasa/metabolismoRESUMEN
Laryngeal mask [LM] airway is commonly used for securing airway in day-care surgeries. Various problems have been described while using LM airway. Out of those, mechanical obstruction causing airway compromise is most common. Here, we describe a case report of 4-year-old child who had partial upper airway obstruction due to LM manufacturer's defect. There was a silicon band in upper one-third of shaft of LM airway. This band was made up of the same material as that of LM airway so it was not identifiable on external inspection of transparent shaft. We suggest that such as non-transparent laryngeal mask, a transparent LM airway should also be inspected looking inside the lumen with naked eyes or by using a probe to rule out any manufacturing defect before its insertion
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Process: Selected members were requested to prepare guidelines on specific issues, which were reviewed by two other members. These guidelines were then incorporated into a draft statement, which was circulated to all members. On 17th December 2011, Kunwar Viren Oswal round table conference was organized by the Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi and the Sub-specialty Chapter of Pediatric Gastroenterology, Indian Academy of Pediatrics. Presentations, ensuing discussions, and opinions expressed by the participants were incorporated into the final draft. Objectives: To formulate comprehensive evidence based guidelines for management of acute liver failure in India, Recommendations: Viral hepatitis is the leading cause of acute liver failure (ALF) in India. Search for metabolic etiology, particularly in infants and neonates, and in apparently idiopathic cases needs to be done. Planning for early transfer is important as the risks involved with patient transport may increase or even preclude transfer at later stages. Management should be in an intensive care setting in select situations. There is currently insufficient evidence to routinely prescribe branched-chain amino acids, non-absorbable antibiotics or lactulose. Group recommends use of N-acetyl cysteine routinely in patients with ALF. Administration of antibiotics is recommended where infection is present or the likelihood of impending sepsis is high. Enteral nutrition is preferred to parenteral nutrition. Protein restriction is not recommended. An international normalized ratio >4 or Factor V concentration of <25% are the best available criteria for listing for liver transplantation. Overall 40-50% of ALF patients survive without transplantation. Survival in patients fulfilling criteria for liver transplantation and not transplanted is 10-20%. Liver transplantation is a definite treatment for ALF with high one-and five-year survival rates.
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The incidence of medications errors is increasing and the exact incidence is likely greatly underestimated and under-reported. Although the majority of these errors occur due to lack of knowledge of or failure to follow accepted protocols, look alike medication containers are the primary cause in many cases of drug error related morbidity or even mortality. With the number of drugs and the number of pharmaceutical companies manufacturing the same drug on an increase, the incidence is likely to increase. It is a universal problem that can be found in any operating room throughout the world, as demonstrated by the multi-national representation of many reports on this subject in the literature. This editorial supplements a case report, the 'Clinipics' Registered page and a special article on the topic of hazards of look-alike drug containers published in this issue of Anaesthsia, Pain and Intensive Care. The authors also attempt to present strategies to reduce these medication errors. The development of a non-blame environment where errors are openly reported and discussed and regulations for labeling the drug containers, vials and ampoules is stressed
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Medication error is a leading cause of morbidity and mortality in anesthesia and critical care unit. We present a case report of a 25 years old female patient, scheduled for emergency lower segment caesarean section [LSCS] under spinal anesthesia. Due to a syringe swap, inj. thiopentone sodium was injected inadvertently, instead of inj. ceftazidime. We had to administer general anesthesia to ventilate the patient, the patient which was otherwise unnecessary in this case. Patient was successfully extubated and shifted to postoperative anesthesia recovery room. We present a second case report of a 45 years old male patient with chronic obstructive pulmonary disease [COPD] admitted in Intensive Care Unit [ICU]. This patient inadvertently received atropine instead of metronidazole and was successfully managed. These incidents highlight the importance of proper drug location, double checking of the drugs, and proper anesthesia resident education
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Simultaneous fracture/dislocation of the thumb carpometacarpal (CMC) joint and dislocation of the metacarpophalangeal (MCP) joint is considered as a rare injury pattern. We report an unusual case of dorsal dislocation of MCP joint of the thumb associated with extraarticular fracture of the base of the first metacarpal in a 28-year-old man. The dislocation of MCP joint had been missed during initial presentation at a peripheral centre. The patient made an uneventful recovery following open reduction and fixation with 1.25 mm Kirschner wire of the MCP joint along with repair of the ulnar collateral ligament. This injury pattern has not been previously reported to the best of our knowledge in the English-language based medical literature.
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Adulto , Humanos , Masculino , Accidentes por Caídas , Hilos Ortopédicos , Diagnóstico por Imagen , Fracturas Óseas , Diagnóstico , Cirugía General , Luxaciones Articulares , Diagnóstico , Cirugía General , Articulación Metacarpofalángica , Heridas y Lesiones , Cirugía General , Procedimientos Ortopédicos , Métodos , Pulgar , Heridas y Lesiones , Cirugía GeneralRESUMEN
Facial prosthesis is generally considered over surgical reconstruction to restore function and appearance in patients with facial defects that resulted from cancer resection. Retention of the prosthesis is challenging due to its size and weight. Retention can be achieved by using medical grade adhesives, resilient attachments, clips and osseointegrated implants. It can also be connected to obturator by magnets. This clinical report highlights the rehabilitation of a lateral midfacial defect with a two piece prosthesis that included an extra oral facial prosthesis and an intraoral obturator with the use of magnets.
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Humanos , Adhesivos , Imanes , Prótesis e Implantes , Retención en PsicologíaRESUMEN
We report two cases of chronic myeloid leukemia (CML) in childhood presenting with monocytosis. History, physical examination and laboratory findings were in favor of juvenile myelomonocytic leukemia in both the cases, but reverse transcriptase polymerase chain reaction (RT-PCR) detected b2a2 and b3a2 transcript of p210 bcr-abl protein characteristic of major BCR breakpoint. Presence of monocytosis in early childhood suggests a viral infection or JMML but a possibility of CML with monocytosis needs to be considered.
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BACKGROUND/OBJECTIVE: There is scant information about atypical (non-diarrheal) presentation of celiac disease (CD) from India. We conducted this study to compare non-diarrheal and diarrheal presentations of CD in children. METHODS: From November 2003 to December 2005, we prospectively screened two groups of children for CD, group I with diarrhea and group II without diarrhea but with atypical presentations (unexplained growth retardation, refractory anemia, refractory rickets, chronic constipation and abdominal distension). Screening was done with IgA antiendomysial antibody (EMA) followed by duodenal biopsy if EMA was positive. Celiac disease was diagnosed according to modified ESPGHAN criteria. RESULTS: A total of 200 children were screened (103 in group I and 97 in group II) and CD was diagnosed in 42 (classical 24, atypical 18). Presentation of atypical CD were; short stature 6, anemia 4, abdominal distension 3, rickets 2, and constipation, diabetes mellitus, delayed puberty in 1 case each. Patients with atypical CD were older (median age 10.4 years vs 5.5 years, p< 0.007) than classical cases. On mean (SD) follow-up of 12.6 (7.5) months all showed response to gluten-free-diet, and median gain in weight, height and final hemoglobin levels were similar in the two groups. CONCLUSION: Atypical CD is not uncommon in India. Children with atypical CD present at an older age. Likelihood of finding CD is high in children with anemia, short stature and rickets.
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Adolescente , Antropometría , Biopsia , Enfermedad Celíaca/diagnóstico , Niño , Preescolar , Diagnóstico Diferencial , Femenino , Humanos , Inmunoglobulina A/sangre , India/epidemiología , Lactante , Masculino , Estudios Prospectivos , Estadísticas no ParamétricasRESUMEN
Helicobacter pylori is causally associated with peptic ulcer disease and gastric carcinoma. Typically children get infected with this organism during the first decade of life but diseases, associated with H. pylori, are seen mainly in adults. In India, almost 80% of population is infected with H. pylori and most of them by 10 years of age. Hence, it is important for a pediatrician to know when to suspect this infection, how to investigate and how to treat it. Extensive electronic (PubMed) literature search was done for this review and literature (randomized controlled trials, clinical trials, meta-analysis, practice guidelines) related to H. pylori in children were reviewed. Special emphasis was given to Indian studies. From this review we can conclude that H. pylori infection is very common in Indian children especially in the low socioeconomic status but most infected children remain asymptomatic through out their childhood and about 15% develop peptic ulcer disease as young adults and 1% develop gastric cancer in older age. There is no association, what so ever, of H. pylori infection and recurrent abdominal pain (RAP). Endoscopy is the preferred method of investigation in children with upper digestive symptoms suggestive of organic disease. Children with H. pylori related disease (peptic ulcer, primary gastric B-cell lymphoma and atrophic gastritis with intestinal metaplasia) but not mere H. pylori infection should be treated with the triple drug regimen comprising of proton pump inhibitor (PPI) and two antibiotics for two weeks.
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Adulto , Niño , Infecciones por Helicobacter/diagnóstico , Helicobacter pylori , Humanos , India/epidemiologíaRESUMEN
This review of the current scenario of celiac disease (CD) in India covers both pediatric and adult CD. CD is primarily reported from northern India with isolated case reports from the rest of the country. CD cases among Indian children are associated with multiple DR3-DQ2 haplotypes. Delay in diagnosis is contributed by multiple factors including atypical presentations. Use of serological tests, IgA EMA and anti-tTG antibodies, along with modified ESPGHAN criteria provides a definitive diagnosis of CD. Dietary management is often difficult due to non-availability of labeled and marketed gluten-free foods. A majority of children with CD show normalization of nutrition, substantial improvement in growth parameters and attainment of healthy percentile curves on gluten-free diet. Small bowel histology remarkably improves but does not normalize even after 2-3 years on gluten-free diet. The true burden of the disease should be addressed by large epidemiological studies.