Changing pattern of rheumatic fever in a paediatric ward : then and now.

Objectives: To describe the socio-demographic and clinical features of children with primary episode of rheumatic fever (RF) during two periods of time and to attempt a comparison of the clinical features with previously published data from the same ward at Lady Ridgeway Hospital (LRH), Colombo. Method: Children admitted to University Paediatric Unit with the primary episode of RF based on the revised Jones criteria, were studied. Socio-demographic and clinical features were recorded prospectively from August 1994 to August 1999 and compared with data collected retrospectively from January 2004 to December 2008. Respecting the limitations, an attempt was made to compare this data with previously published data from the same ward during a period of ten years from 1966, when the primary episode of RF was diagnosed based on the modified Jones criteria. Results: There were 91 children from 1994 to 1999 and 52 (57%) were boys. Majority were >5 years and from families with a monthly income <Rs.10,000.00 but 56 (62%) of their mothers were educated up to Grade 10. Migratory polyarthritis was seen in 56 (62%) and 58 (64%) had a significant murmur on admission. Echocardiography was done on 87 and 24 (28%) had evidence of rheumatic heart disease (RHD). There were 29 (17 boys) during the 4 years from January 2004. Echocardiography was done on all the patients and 8 (28%) had RHD. During 1966 - 1976, RHD diagnosed on clinical features, was reported in 42% of 158 children (92 girls). Chorea has progressively increased through the years, with girls being more commonly affected. Conclusions: Childhood RF has declined in Sri Lanka. Disease pattern has also changed with more boys being affected but chorea continues to manifest more commonly in girls. RHD continues to be an important manifestation.

Variation in the origin of the posterior cerebral artery in adult Sri Lankans.

BACKGROUND: The degree of contribution from the vertebro-basilar and carotid systems to the origin of the posterior cerebral artery (PCA) is of clinico-anatomical importance. Three configurations in the bifurcation of the posterior communicating artery (PcomA) have been described, foetal, transitional and adult. OBJECTIVE: To examine the extent of contribution from the vertebro-basilar and carotid systems to the origin of the PCA in adult autopsy brains in subjects who had died of causes unrelated to the brain. MATERIALS AND METHODS: The external diameter of the PcomA, pre communicating part (P1) and the post communicating part (P2) of PCA in 225 normal Sri Lankan adult cadaver brains was measured using a calibrated grid. Results: The adult configuration was present in 220 (93.3%); (bilaterally in 200 (88.8%), and unilaterally in 20 (8.8%) ten on each side. Foetal configuration was seen in 17 (4.4%); bilaterally in 3 (1.3%), and unilaterally in 14 (6%) 8 on the left and 6 on the right. Transitional configuration was seen in 8 (2.2%); bilaterally in 2 (0.9%), and unilaterally in 6 (2.5%) 2 on the left and 4 on the right. CONCLUSION: This study reveals that the internal carotid artery (ICA) provided the major supply to the PCA in 4.4% of foetal and 2.2% of transitional configurations. The adult configuration was present in 220 (93.3%), the highest recorded in the literature. This finding may be of relevance to vertebrobasilar ischaemia and infarcts in the territory of the PCA.

Analysis of medical records of patients with “other neurological diseases” admitted to Lady Ridgeway Hospital.

Objective To assess the frequency of diseases categorized under "other neurological diseases" in the Indoor Morbidity and Mortality Registry (IMMR) of the Medical Record Unit of infants and children admitted to the Lady Ridgeway Hospital for Children (LRH) and coded and indexed according to the 10th revision of the International Classification of Diseases (ICD 10) of the World Health Organization. Design Retrospective data analysis Method Data of in-ward patients, obtained from the medical record section of LRH for a period of two years (2004 and 2005), were analysed Results Two hundred and ninety nine (0.21%) [157 (52.5%) males and 142 (47.5%) females] had been categorized under "other neurological diseases". The four major contributors were hydrocephalus 59 (20%), polyneuropathy & disorders of peripheral nervous system 44 (15%), Guillain Barre' syndrome 39 (13%) and disorders of myoneural junction & muscle 29 (10%). A family history was present in a patient with Duchenne muscular dystrophy (DMD) and a patient with limb-girdle muscular dystrophy.

Changes in erythrocyte glucose-6-phosphate dehydrogenase (G6PD) and reduced glutathione (GSH) activities in the development of senile and diabetic cataracts.

Oxidative and osmotic stress have been implicated in the pathogenesis of cataracts. Reactive oxygen intermediates (ROI) mediate peroxidation of membrane lipids and cause irreversible damage to lens proteins. The purpose of this study was to assess the changes in erythrocyte glucose- 6-phosphate dehydrogenase enzyme (G6PD) and reduced glutathione (GSH) levels in the development of senile and diabetic cataracts. The activity of erythrocyte G6PD and the concentration of GSH were measured to assess changes in oxidation-reduction status. The oxidation-reduction status of 26 non-diabetic non-cataract (control) subjects were compared with 24 diabetic non-cataract, 30 diabetic cataract and 28 non-diabetic cataract subjects. The results revealed that the GSH and G6PD levels of the subjects with senile cataracts were significantly lower than the subjects without cataracts. The present study reveals the risk of developing senile cataracts is associated with decreased levels of erythrocyte G6PD and GSH. In the formation of diabetic cataracts an adequate supply of NADPH (G6PD activity) is essential to produce osmotically active sorbitol in the lens.

Prevalence of talipes equinovarus, congenital dislocation of the hip, cleft lip/cleft palate, Down syndrome and neural tube defects among live newborns in Anuradhapura, Sri Lanka.

Objective To determine the prevalence of talipes equinovarus, congenital dislocation of the hip, cleft lip/cleft palate, Down syndrome and neural tube defects among live newborns at Anuradhapura General Hospital, Sri Lanka. Method Babies born from February 2002 to January 2003 were examined for the above five congenital anomalies. Anomalies were recorded in a register and live birth prevalence rate (LBPR) for each anomaly was calculated. Results 9105 newborns were examined for the 5 selected congenital anomalies. LBPR per 10,000 live births of the 5 anomalies were as follows: talipes equinovarus 31.8, congenital dislocation of hip 26.3, cleft lip/cleft palate 21.9, Down syndrome 20.8 and neural tube defects 13.2.

Metabolic consequences of childhood obesity--a preliminary report.

INTRODUCTION: Childhood obesity is increasing in Sri Lanka. Obesity related morbidity is mainly associated with the metabolic syndrome (MetS) and non-alcoholic steatohepatitis (NASH). Recent studies have shown these serious health consequences in obese children. OBJECTIVES: The objectives of our study were to document the presence of MetS and NASH in obese Sri Lankan children, to correlate the fat mass (FM) with the waist circumference (WC) and the body mass index (BMI), and to compare the association of the WC, BMI and the WHR (waist-hip ratio) with the metabolic derangements. METHOD: Children attending the Obesity Clinic at Lady Ridgeway Hospital, Colombo, from November 2004 to September 2005 were studied. The relevant sociodemographic data, anthropometric measurements and examination findings were documented. After a 12-hour overnight fast, blood was taken for estimation of lipid profile, serum insulin, liver enzymes and blood glucose. The oral glucose tolerance test (OGTT) was done in children over 5 years of age. Fatty infiltration of the liver was assessed by identifying specific features on ultrasonography and the degree of infiltration was given a score. We modified the International Diabetes Federation (IDF) 2004 guidelines to define MetS. NASH was defined as fatty infiltration of the liver associated with a raised serum ALT. RESULTS: Seventy children (40 boys) were studied. The mean (SD) age was 9.7 (2.5) and 9.3 (3.0) years for boys and girls respectively. Mean BMI was 25.9 in both groups. All patients had a WC > 98th percentile. MetS was found in 13 of the 63 (21%) children on whom all criteria were assessed. Sixty children had ultrasonography and NASH was seen in 11 (18%). The correlation of the percentage FM was greater with the BMI (r = 0.80; p < 0.001) than with the WC (r = 0.56; p < 0.001), but the WC was more significantly associated with the metabolic derangements than either BMI or WHR. CONCLUSIONS: Serious metabolic abnormalities are found in obese Sri Lankan children and the WC is a reliable indicator of these derangements.

Comparison of phalangeal bone mineral content and density between the dominant and non-dominant sides.

OBJECTIVES: Compared to the non-dominant side, higher bone mineral content (BMC) and density (BMD) have been demonstrated in the forearm bones in the dominant side. Clinicians are compelled to scan the dominant side when deformities or artifacts are found in the non-dominant side. This study was done to evaluate the differences in phalangeal BMC and BMD, measured using accuDXA, between the dominant and non-dominant hands. Design and participants A group of 333 subjects, comprising 267 healthy volunteers (185 women and 82 men) and 66 women with rheumatoid arthritis. Phalangeal BMD and BMC, were measured using accuDEXA, both in the non-dominant and dominant hands. Main results BMC and BMD showed strong correlations between the two sides (r = 0.95, p < 0.001 for both). Compared to the non-dominant side, dominant side BMC was 5% higher (mean values =1.54 and 1.47, mean difference = 0.064, 95% CI for the mean difference = 0.048-0.081 g, p < 0.001) and BMD was 4% higher (mean values = 0.480 and 0.463, mean difference = 0.018, 95% CI for the mean difference = 0.014-0.021 g/cm2, p < 0.001). In the subgroup analysis, percentage differences of BMD between the two sides were found to be similar among men (n=82), women (n=251), people below 50 years (n=24), people above 50 years (n=122) and also among patients with rheumatoid arthritis (n=66). Conclusions When the non-dominant hand is not suitable for scanning, the clinician should consider scanning the dominant hand instead. However, the differences in BMD between the two hands should be taken into consideration when interpreting results.

Sociodemographic and health aspects of mothers in a paediatric ward.

Objectives To study a group of mothers in a paediatric ward and describe sociodemographic profile, presence of existing disease, pulse and blood pressure (BP) profiles during hospital stay, psychological profile prior to admission and changes demonstrated during period of stay. Method A descriptive, cross-sectional study was done in a ward at Lady Ridgeway Hospital for 6 weeks from May 2004. Five hundred mothers staying with their sick children were interviewed using a questionnaire dealing with various aspects. Mothers of children with chronic diseases needing regular admissions and those transferred to and from ward were excluded. Pulse rate and BP of mothers were recorded on admission, within 24 hours and on discharge. Psychological profile was assessed as psychological score, describing behaviour prior to admission, and acute stress score, analysing changes demonstrated during present admission. This was done using a scoring system on a standard questionnaire with 23 items and a modified one with 5 items where higher scores identified mothers reacting more to stressful situations. Results 476 (95.2%) questionnaires were analysed. Mean age of mothers was 32.1 years with a range of 17 to 52 years. 442 (92.9%) mothers had received secondary or higher education but 8 had never been to school. Monthly income was <Rs.10,000 in 296 (62.2%) families and 385 (80.9%) children were from middle and lower social classes. 117 (24.6%) mothers had preschool children at home when they were in hospital, majority of whom were looked after by grandparents. 65 (13.7%) mothers had long standing illnesses needing daily medication but only 15 (23.1%) took the drugs while in hospital. 54 (11.3%) mothers did not have anyone to confide in when they had a problem. Mean pulse rate and systolic and diastolic BP on discharge were significantly lower than the mean values on admission. Highest mean psychological score of 26.4 was found in the 21-30 year age group. Significantly higher acute stress scores were found in mothers below 30 years and in those who did not have anyone to confide in. Conclusions This study demonstrates that mothers who play a vital role in management of their sick children are under immense stress and have their own health issues and family commitments that are mostly not appreciated or addressed. A social worker assigned to paediatric wards could provide invaluable help to mothers to cope with the stressful situation of hospitalisation of a sick child.

Seroprevalence of hepatitis A antibodies in relation to social factors--a preliminary study.

INTRODUCTION: Hepatitis A is a benign illness in children with the rare possibility of fatal complications. Although an endemic disease, very few studies have been done in children regarding the seroprevalence of hepatitis A antibodies in Sri Lanka. OBJECTIVES: (i) To document the seropositivity for hepatitis A in a group of children admitted to a paediatric ward. (ii) To determine the relationship of hepatitis A viral infection to social factors in these children. METHOD: A prospective, descriptive, cross-sectional study was carried out in a ward at the Lady Ridgeway Hospital for 7 months from September 2001. Children admitted on predetermined days, needing venepuncture for their presenting illness, were studied while those who were seriously ill were excluded. Written consent was obtained and a questionnaire with details of socio-economic conditions, personal hygiene practices of the mother, access to water and sanitation and health related behaviour was administered. Total antibodies to hepatitis A were detected by ELISA on a sample of blood taken from each patient. RESULTS: Two hundred and eighty eight samples of blood were analysed. None of the children were immunised against hepatitis A. There were 158 boys (54.9%). Thirty one (10.8%) of the 288 patients had antibodies against hepatitis A. The seroprevalence was 11.6% in children under 10 years of age. Majority (78%) were from families with a monthly income of less than Rs 10,000/-. Fifteen (48.4%) of the 31 seropositive children were from families earning less than Rs 5000/- per month. Belonging to social classes IV and V and having mothers with only primary education were factors significantly associated with seropositivity. No significant difference in the presence of antibodies was observed regarding the personal hygiene practices analysed and access to basic amenities. Health related behaviour practices analysed were significantly associated with the presence of hepatitis A antibodies. CONCLUSIONS: Seroprevalence of 10.8% was observed in a selected group of children. Factors such as poor socio-economic background and having mothers with only primary education were associated with hepatitis A virus (HAV) antibodies as were certain health related behaviour practices of children.

Clinical examination in paediatrics at final MBBS: views of children and their parents.

INTRODUCTION: The final examination in paediatrics for medical undergraduates in Sri Lanka consists of a written and a clinical component. Each candidate at the clinical component sees one long case and two short cases. OBJECTIVES: To assess the views of the bystanders regarding their sick children participating at a clinical examination, and to evaluate the children's perceptions of the clinical component. METHODS: An interviewer-administered questionnaire was discussed separately with the participating children and their bystanders at the final year examination in paediatrics of the Faculty of Medicine, Colombo, in 1999. RESULTS: 116 patients participated at the clinical examination in paediatrics. 107 (92%) of the bystanders were the children's mothers. Informed consent had not been obtained for use in the examination from 59 (51%) of the children's mothers. Seven (6%) were not satisfied with the way their children were handled by the candidates, and 25 (21.5%) showed concern about the number of candidates examining their child. Bystanders who participated at the long cases were inconvenience more than those in the short cases. 34 children above the age of 5 years were also interviewed. An explanation regarding the examination had not been given to 31 (92%) of them. Six children (17%) said they were examined for too long. A majority of the bystanders welcomed the payments received and all of them were satisfied with the medical students' conduct and politeness. All of them agreed that this form of clinical examination was a good method of evaluating a student's professional competence. CONCLUSIONS: Several aspects of the clinical component of the final examination in paediatrics for medical undergraduates need to be improved to minimise the inconvenience experienced by the children and their parents.