Influence of exclusive breast feeding on occurrence, severity and recurrence of acute lower respiratory infections in preschool children.

Objective: To determine the association between acute lower respiratory infections (ALRI) and exclusive breast feeding practices in children younger than five years of age Design: Case control study Setting: Lady Ridgeway Hospital for Children, Colombo. Method: Breast feeding practices in children younger than five years of age admitted with ALRI were compared with that of age and gender matched controls. An interviewer administered structured pretested questionnaire was used to collect the data. Results: One hundred and four cases and controls were studied; 53% of cases were exclusively breast fed for four or more months compared to 68% of controls (odds-ratio 2). Of the 14 cases with severe ALRI, 14% were exclusively breast fed for four or more months compared to 56% in non severe ALRI cases (odds-ratio 7.5). Proportion of children exclusively breast fed for four or more months was significantly lower (p < 0.001) in cases who had previous hospital admissions for ALRI (31% against 62%). Conclusions: This study provides further evidence that exclusive breast feeding has protective effect on occurrence, severity and recurrence of ALRI in young children.

Management of acute paracetamol poisoning in a tertiary care hospital.

OBJECTIVES: To compare the management of acute paracetamol poisoning with the best evidence available, and to determine the effect of plasma paracetamol level estimation on the management. DESIGN: Descriptive study with an intervention. SETTING: Medical wards of the National Hospital of Sri Lanka, Colombo. PATIENTS: Patients admitted with a history of acute paracetamol poisoning. INTERVENTION: Measurement of plasma paracetamol. METHODS: Data were obtained from the patients, medical staff and medical records. Plasma paracetamol was estimated between 4-24 hours of paracetamol ingestion. The current management practices were compared with the best evidence on acute paracetamol poisoning management. RESULTS: 157 patients were included. The mean ingested dose of paracetamol was 333 mg/kg body weight. Majority of the patients (84%) were transfers. Induced emesis and activated charcoal were given to 91% of patients. N-acetylcysteine was given to 66, methionine to 55, and both to 2. Aclinically important delay in the administration of antidotes was noted; 68% of patients received antidotes after 8 hours of the acute ingestion. Only 31 (26%) had paracetamol levels above the Rumack-Matthew normogram. 74 patients received an antidote despite having a plasma paracetamol level below the toxic level according to the normogram. INTERPRETATION: Management of acute paracetamol poisoning could be improved by following best available evidence and adapting cheaper methods for plasma paracetamol estimation.

Fulminant hepatic failure and paracetamol overuse with therapeutic intent in febrile children.

OBJECTIVE: To evaluate the risk of fulminant hepatic failure in relation to paracetamol overuse with therapeutic intent in febrile children. METHODS: It was a case control study. Paracetamol ingestion for the current febrile illness was compared between 25 cases of fulminant hepatic failure and 33 hospital age matched controls. RESULTS: Supra-therapeutic doses of paracetamol (mean 145 mg/kg/day) were consumed by all 25 cases compared to none in the control group. Mean paracetamol level in the cases and controls were, respectively, 26.84 mg /dl and 0.051 mg /dl (p< 0.001). The mean duration of paracetamol intake prior to admission in cases was 3. 45 days compared to 1.85 days in the control group. Nineteen, 5 and 3 were, respectively, graded as hepatic encephalopathy grade 1, 2 and 3. All six patients in grade 2 and 3 had hepatomegaly compared to 78% in the grade 1. Four had jaundice and all were in grade 2 or 3. Mean alanine aminotransferase was 2781 U/L None of the randomly selected cases (6) had serological evidence of Hepatitis A, Hepatitis B or Dengue. Three cases died. CONCLUSION: Exposure to multiple supratherapeutic doses of paracetamol is a risk factor to develop fulminant hepatic failure in children with an acute viral like febrile illness.

Estimation of iodine in salt fortified with iodine & iron.

BACKGROUND & OBJECTIVE: The National Institute of Nutrition (NIN), Hyderabad has developed double fortified salt (DFS) containing both iodine and iron to control the twin problems of iodine deficiency disorders (IDD) and iron deficiency anaemia (IDA). When the iodine content of DFS was estimated by the conventional iodometric titration using sulphuric acid (H(2)SO(4)), problems such as wide variation between duplicate analysis and under/overestimations of iodine content were encountered, which led to inconsistent results. This study was undertaken to develop a modified method for the estimation of iodine in DFS so as to get reliable iodine content of DFS. METHODS: A modified method was developed using orthophosphoric acid (H(3)PO(4)) and the sensitivity of the method was confirmed by estimating the iodine content of potassium iodate (KIO(3)) standard at different concentrations of iodine (0 to 100 ppm). The iodine content of DFS and iodized salt (IS) from local market and factory was estimated by the modified method as well as the conventional iodometric titration and the results were compared. RESULTS: The pH of DFS was acidic. The time gap between the additions of acid and potassium iodide (KI) played a crucial role in getting the actual iodine content of DFS. The H(2)SO(4) and ferrous sulphate (FeSO(4)) interfered with the estimation of iodine in DFS resulting in underestimation or overestimation of iodine. Modified method (H(3)PO(4)) produced consistent and reliable iodine content of DFS. Both H(2)SO(4) and H(3)PO(4) gave same results when tested with KIO(3) standard, Reference salt and IS (both experimental and purchased from local market). Actually 0.50 ml of 1 per cent KI was sufficient to estimate the iodine content of DFS or IS. INTERPRETATION & CONCLUSION: The results of the present study showed that the conventional method using H(2)SO(4) was not suitable for the estimation of iodine in DFS. The modified method using H(2)PO(4) was ideally suited for the estimation of iodine in DFS. Also, iron from DFS did not interfere during estimation of iodine by this method. As both the conventional and the modified methods gave the same results for the iodine content of IS, it is practically prudent to use the modified method (H(2)PO(4)) for both DFS and IS instead of following one method (H(3)PO(4)) for DFS and another (H(2)SO(4)) for IS. The quantity of KI is also reduced and the order of additions of reagents is changed in the modified procedure.

Effect of hypoxia on the circulating levels of essential mineral elements in rats.

Changes occurring in concentrations of certain trace metals and electrolytes viz. chromium, copper, zinc, sodium, potassium, calcium, magenesium and chloride in plasma of rats exposed to intermittent hypobaric hypoxia were evaluated. Batches of Sprague-Dowley rats (12 in each group) were exposed for 1, 7,14 and 21 days to a simulated altitude 7,620 m for 6 h per day and one group of unexposed animals was kept as control. There was a significant rise of 153% in plasma chromium levels of 1 day exposed group in comparison to the unexposed group which tends to normalise on subsequent exposure. There was a gradual increase in plasma copper levels of 9.0, 28.2, 62.6 and 65.6% respectively in 1,7,14 and 21 days exposed rats in comparison to unexposed rats. On the other hand plasma zinc levels were seen to be decreasing during entire exposure. Plasma sodium levels decreased initially in 1 and 7 day exposed rats and increased in later groups whereas plasma potassium levels of exposed groups remained low in comparison to unexposed group. Chloride levels were found to be elevated in 14 and 21 day exposed groups.The plasma calcium and magnesium levels were higher in all exposed groups over unexposed groups. Changes in chromium, copper and zinc observed in the present study during exposure to hypoxic stress may be responsible for the hyperglycemia and anorexia encountered during intial phase of high altitude acclimatisation.

Impact evaluation of iron & iodine fortified salt.

As a novel approach to tackle the problems of iron deficiency anaemia and iodine deficiency disorders (IDDs), which often coexist, the National Institute of Nutrition has developed iron and iodine fortified common salt (double fortified salt-DFS) as a public health measure. This salt has undergone a battery of laboratory and field tests to evaluate its feasibility for use in a national programme. The DFS is designed to provide 1 mg of iron and 15 micrograms of iodine per gram of common salt. This was made possible by the inclusion of a polyphosphate stabilizer, sodium hexametaphosphate (SHMP) at 1 per cent level. The stability of iron and iodine was found to be good up to 6 months. However, the stability of iodine depended upon the quality of the salt used for fortification. The biological effects of long-term consumption of DFS were evaluated in experimental rats and in field trials. Both iron and iodine from the salt were found to be biologically available in regenerating haemoglobin and in increasing excretion of iodine in urine. When this salt was tested in tribal villages endemic for goitre and iron deficiency anaemia, the bioresponse was good with regard to the iodine status but was not uniform in all segments with regard to iron, probably due to confounding variables. In a study carried out in residential school children where such variables did not exist, DFS was found to have significant impact on haemoglobin status in anaemic children and improved their urinary iodine excretion. The consumption of DFS for 2 yr did not have any adverse effects in school children as well as in the tribal population. Parameters related to calcium homeostasis were not altered in children receiving DFS. Histopathological examination of tissues and radiological examination of bone did not reveal any abnormality in DFS fed rats. Similarly serum and urinary parameters related to calcium and phosphorus were not altered in DFS fed rats. Therefore, DFS is presented as a feasible and effective strategy to control the double deficiency of iron and iodine in our community.

Renal amyloidosis--a clinicopathologic study.

A total of 19,075 necropsies and 1169 renal biopsies were scrutinised over a period of 20 years (1973-1992) retrospectively with an aim to study the incidence and pattern of renal amyloidosis in Nair Hospital. A total of 75 cases with amyloidosis were detected, 33 from the necropsy series (0.162%) and 42 from biopsies (3.59%). Secondary amyloidosis was seen in 82.66% and primary amyloidosis in 10.66%. Tuberculosis of various organs was the main cause of secondary amyloidosis (79.03%). Nephrotic syndrome was the common mode of presentation (52%). Besides kidney, which were involved in all cases, the liver, spleen and adrenals were other commonly involved organs at necropsy. Renal failure was the leading cause of death (51.51%). Thioflavine-T proved to be more sensitive technique than other conventional staining methods. The potassium permanganate test is a useful test to distinguish secondary amyloid fibrils from other amyloid fibrils. Abdominal fat aspiration may prove to be specific, sensitive and a routine procedure enabling the early diagnosis of amyloidosis leading to increased incidence of amyloidosis during life than at necropsy.

Human requirements of iodine & safe use of iodised salt.

Iodine deficiency is the most common preventable cause of mental deficiency. Remarkable success has been achieved by the use of iodised salt to correct this deficiency in many industrialised countries since 1920. The Government of India has adopted a strategy to iodise all edible salt in the country to overcome iodine deficiency. Universal salt iodisation is the principal public health measure for eliminating iodine deficiency disorders. Daily iodine intakes of up to 1000 micrograms, appear to be entirely safe. In India, the likelihood of exceeding this level is quite small. Iodised salt does not cause any side effects. Iodine in iodised salt does not carry risks for persons who are already iodine sufficient. iodisation of salt at the current level of fortification (15-30 ppm iodine) keeps intakes well within a safe daily range for all populations, irrespective of their iodine status.

Iodised salt is safe.

Iodine deficiency disorders are prevalent in all the States and Union Territories in India. Under the National Iodine Deficiency Disorders control programme, the Government of India has adopted a strategy to iodisation of all edible salt in the country which is a long term and sustainable preventive solution to eliminate iodine deficiency disorders. The benefits to be derived from universal salt iodisation are more to the population. Iodised salt is safe and does not cause any side effect.

Helicobacter pylori in normal gastric mucosa.

Since the discovery of Helicobacter pylori (H. pylori) in 1983 several studies have established relationship of H. pylori with gastritis, duodenal ulcer disease and gastric carcinoma. H. pylori infection is widely prevalent and exposure occurs at younger age in our country. Several Western studies have shown prevalence of H. pylori in normal gastric mucosa to range from 0-25%. As similar information is not available from our country we estimated the prevalence of H. pylori in histologically normal gastric mucosa. Of the 50 asymptomatic volunteers studied, 33 showed histological evidence of gastritis and 28 of these were H. pylori. We conclude that histological gastritis is very common in young asymptomatic Indians and H. pylori infection is noticed in almost 25% subjects with histologically normal gastric mucosa.

Gastric metaplasia and Helicobacter pylori infection in intestinal tuberculosis.

BACKGROUND: Gastric metaplasia occurs in intestinal epithelium of patients with Helicobacter pylori infection as well as intestinal tuberculosis, but the relationship between the three is not clear. SETTING: Teaching hospital. METHODS: Staining of intestinal sections from patients with ileocecal tuberculosis for H pylori and for metaplasia. RESULTS: Twenty seven of 92 (29.3%) patients demonstrated gastric metaplasia (superficial epithelial and pyloric gland metaplasia) in resected specimens of ileum. Gastric metaplasia was of antral type in all 27 patients. Helicobacter pylori was present in 3 of 27 (11%) patients with gastric metaplasia and was absent in all 65 patients without metaplasia. CONCLUSION: Gastric metaplasia (both superficial epithelial and pyloric gland) occurs in one-third of patients with ileocecal tuberculosis and such mucosa is poorly colonized by H pylori.

Heterotopic gastric mucosa and Helicobacter pylori infection in Meckel's diverticulum in Indian subjects.

Two of twenty nine (6.8%) patients who had undergone resection of Meckel's diverticulum demonstrated heterotopic gastric mucosa. In both these patients gastric mucosa was of antral type. Remaining 27 of 29 (93.2%) patients with Meckel's diverticulum had intestinal mucosa. 9 of 29 (31%) patients with Meckel's resected were symptomatic (8 bleeding, 1 perforation) and all 9 were negative for heterotopic gastric mucosa. Helicobacter pylori (H. pylori) was absent in both patients with intestinal mucosa. Antral biopsy from 13 partial gastrectomy specimens (surgery done for carcinoma stomach) were used as methodological controls and 7 of 13 (54%) showed H. pylori colonization. We conclude that (i) incidence of gastric mucosa is 6.8% in Meckel's diverticulum in our population, (ii) presence of heterotopic gastric mucosa is unlikely to be associated with complications of Meckel's diverticulum and (iii) heterotopic mucosa in Meckel's diverticulum is not commonly colonized by H. pylori.

Mono and dual therapy for Helicobacter pylori associated gastritis.

Sixty patients with Helicobacter Pylori positive non ulcer dyspepsia were randomly allocated to one of the following treatment groups: Group I--norfloxacin 400 mg bid for 10 days, Group II--amoxycillin 500 mg bid plus tinidazole 500 mg bid for 15 days, Group III--colloidal bismuth subcitrate (CBS) 240 mg bid for 4 weeks. H pylori elimination was achieved in 14%, 81%, and 62% in Groups I, II and III respectively. Eradication of H pylori was not observed in Groups I and II, but was achieved in 25% of patients in Group III. Antral gastritis improved in 69% in Group II and 50% in Group III. We conclude that norfloxacin is not effective in H pylori infection. A combination of amoxycillin and tinidazole is highly effective in H pylori elimination with improvement in associated gastritis, but H pylori eradication is not observed with this therapy. CBS is also effective in H pylori elimination though H pylori eradication is achieved in only 25%.