Effect of vitamin A supplementation on childhood morbidity and mortality.

In a double blind design, 1520 children aged < 10 years were individually randomised in vitamin A and placebo group in slums of Chandigarh. Children > 12, 6-12 and < 6 months of age received 200,000, 100,000, 500,000 I.U. of vitamin A respectively every 4 to 6 months during 15 months trial period. The prevalence of vitamin A deficiency was significantly reduced in vitamin A compared to placebo group during the follow-up period. In vitamin A group, incidence of diarrhoea and measles was significantly reduced but incidence of acute respiratory infections was not significantly different compared to control group. Risk of death was also significantly less in vitamin A group. Therefore, promotion of vitamin A rich diet or supplementation with synthetic vitamin A at 4-6 month interval should be a priority in populations where risk of vitamin A deficiency is high.

Identification of a novel copper-binding protein from the liver of Indian childhood cirrhosis: purification and physicochemical characterization [corrected].

A novel copper-binding protein was identified in the liver supernatant (100,000 x g) of Indian childhood cirrhosis (ICC), purified to apparent homogeneity and characterized [corrected]. Purified major copper-binding protein (MCuBP) is solely responsible for binding about 35% of the total supernatant copper. Elution profile of ICC liver supernatant on Sephadex G-75 column chromatography showed three peaks. About 60% of the total supernatant copper was resolved in peak II, whereas zinc content was insignificant in this peak. But peak II was almost missing in a gel elution profile of control liver supernatant. The control group included cases of various liver diseases viz. neonatal hepatitis, septicemia, and mixed nodular cirrhosis. Copper-binding proteins of peak II further purified on ion-exchange chromatography and elution profile showed that peak II was a MCuBP with high copper-binding capacity (10 g atoms/mol of native protein). SDS-PAGE of this protein also revealed the existence of a single band with molecular mass of about 50 kD. UV spectra of MCuBP showed the maximal absorbance at 254 nm. Unlike the classical metallothionein, the amino acid composition of MCuBP revealed the presence of aromatic amino acids and higher content of glutamic acid and aspartic acid followed by glycine and serine. The ratio (0.3) of basic amino acids to acidic amino acids strongly indicates that it is an acidic protein. The cysteine content in this protein was insignificant, which further corroborates the possibility that the acidic amino acids might be prominent candidates for binding copper. Thus, the 50-kD MCuBP apparently makes a major contribution to the total copper-binding activity in ICC liver cytosol and may play a significant role in hepatic intracellular copper accumulation.

A critical evaluation of copper metabolism in Indian Wilson's disease children with special reference to their phenotypes and relatives.

Wilson's disease is an autosomal recessive disorder of copper accumulation in various organs, with most common clinical manifestations such as hepatic, neurological, and renal dysfunctions. Serum copper and ceruloplasmin in Wilson's disease were significantly lower as compared to normals, controls, and relatives of Wilson's disease patients, whereas marked hypercupriuria (145+/-7 microg/24 h) was observed in Wilson's children only. A good correlation (r=0.92) was found between non-ceruloplasmin-bound copper and 24-h urinary copper excretion in Wilson's disease patients. Further, copper studies among the different phenotypes of Wilson's disease revealed substantially low serum ceruloplasmin and a marked hypercupriuria in Wilson's disease children associated with renal tubular acidosis as compared to the patients with either hepatological or neurological manifestations. Serum ceruloplasmin levels in 14 patients of Wilson's disease were between 14 and 20 mg/dL. These patients of Wilson's disease were confirmed by measuring liver biopsy copper, which was about nine times higher than normal hepatic copper content. During the family screening by copper studies, four asymptomatic siblings were diagnosed for Wilson's disease. These subjects were then started on D-penicillamine therapy because presymptomatic treatment prevents progression of the disease complications.

Dynamics of conjunctival impression cytologic changes after vitamin A supplementation.

To investigate the chronological changes in conjunctival epithelium after supplementation with a massive oral dose of vitamin A, conjunctival impression cytology (CIC) with transfer was carried out repeatedly among 200 children aged 6-120 months in a randomized, double-blind, placebo-controlled study in Chandigarh (India). Significant conversion to normal CIC started 71-80 d after vitamin A supplementation and by 101-110 d conversion had taken place in all children. Compared with the placebo group, plasma retinol concentration at 100 d post-supplement was found to be significantly higher in the vitamin A-supplemented group P = 0.04. This study demonstrates that CIC responds to a massive oral dose of vitamin A 3-4 months after supplementation. These findings should guide future studies and evaluations in which CIC is used to assess response to vitamin A interventions.

Percentile curves for body-mass index of Punjabi infants.

OBJECTIVE: To study percentile distance growth pattern of Body Mass Index (BMI) of Punjabi male and female infants. DESIGN: Longitudinal. SETTING: Growth Clinic. SUBJECTS: 154 Punjabi infants (Male 86; Female 68), aged birth-12 months. FOLLOW-UP: Nude body weight and crownheel length of all babies at birth and whereafter, were measured at monthly age intervals with time tolerance to +/-3 days by the same investigator upto 12 months of life. RESULTS: Mean (+/- SD) values for BMI measured 12.2 +/- 1.40 kg/m2 and 16.5 +/- 1.40 kg/m2 at birth and 12 months, respectively in male infants. The corresponding figures for female infants were 12.5 +/- 1.60 kg/ m2 and 16.5 +/- 1.50 kg/m2. A rapid increase in BMI values amongst infants of both sexes between birth to about six months followed by flattening of curves upto 12 months of age indicates an age dependent nature of BMI during first half of infancy in comparison to latter half during which these demonstrated stable trend. These findings are in contrast to those of the western infants who showed a regular increase in BMI throughout the first year of life. Sex differences were not significant at majority of the age levels. CONCLUSIONS: Percentile grids presented for BMI represent a normal, healthy and well-nourished infant population which can be used to assess the adiposity status of infants of the two sexes during the first year of life.

Conjunctival impression cytology with transfer (CICT) to detect pre-clinical vitamin A deficiency among slum children in India.

In order to establish a method usable in the field for diagnosis of pre-clinical vitamin A deficiency, conjunctival impression cytology with transfer (CICT) was used in 200 normal slum children aged 6-120 months in Chandigarh, India. Conjunctival impressions taken on cellulose acetate paper were transferred to glass slides which were fixed in ethanol and stained with alcian blue and carbol fuchsin. Sixty samples of cellulose acetate paper were preserved after transfer of impression and were stained later. Transfer was complete in forty-eight samples and in the other twelve it was incomplete. Conjunctival impressions on paper and slide of these twelve cases were comparable. At a plasma retinol concentration of < 0.70 mumol/l measured by HPLC the sensitivity, specificity and positive predictive values of CICT were 90.59%, 100% and 100% respectively. Compared with conventional conjunctival impression cytology, CICT is less time consuming, cheaper and comparable in validity. It is thus more suitable than the conventional method for mass screening.

Molecular basis of pathophysiology of Indian childhood cirrhosis: role of nuclear copper accumulation in liver.

Indian Childhood Cirrhosis (ICC) is a disease of abnormal copper metabolism commonly characterized by swelling and degeneration of liver cells along with the presence of orcein staining deposits of copper. Hepatic copper content of ICC patients was about 43 fold higher than those of control subjects. The data on sub-cellular distribution of copper revealed massive accumulation of Copper (73%) of total cell copper) in the nuclear fraction (455 micrograms Cu/g tissue nuclei). On further distribution of copper in nuclear fraction, the enrichment of copper in heterochromatin and euchromatin of ICC nuclei was found to be 48 and 15 fold higher over control fractions respectively. The ultra-violet spectra of heterochromatin and euchromatin isolated from ICC nuclear fraction showed a broad absorption maxima as compared to controls. Further, A260/A280 ratio was markedly lower in heterochromatin and euchromatin of ICC liver in comparison to controls. An antioxidant enzyme, catalase activity was also significantly reduced in ICC liver as compared to control. Further, DNA fragmentation studies indicated that there was significantly increased DNA fragmentation in ICC liver. Collectively, these findings suggest that massive accumulation of copper in nucleus and decrease in catalase activity was associated with DNA fragmentation in hepatocyte of ICC disease.

51Cr-labelled ethylenediaminetetraacetic acid and D-xylose absorption test in Escherichia coli enterotoxin-induced diarrhoea in mice.

BACKGROUND AND METHODS: D-Xylose and 51Cr-labelled ethylenediaminetetraacetic acid (EDTA) absorption tests were evaluated in control and Escherichia coli heat-stable, heat-labile, and both heat-stable and heat-labile enterotoxin-induced diarrhoea in mice. RESULTS: The absorption of D-xylose was greatest 45 min after its ingestion in both control and enterotoxin-treated groups. There was a significant (p < 0.01) decrease in xylose absorption at 45 min in all the three experimental groups as compared with the control group, which may be due to change in membrane fluidity and hence change in membrane permeability, whereas 51Cr-EDTA absorption was at its maximum 15 min after its ingestion in both control and experimental groups. And there was a significant (p < 0.05) increase in 51Cr-EDTA absorption in enterotoxin-treated groups as compared with the control group. CONCLUSIONS: These results suggest a change in tight junctional permeability which may be due to change in the cytoskeletal microfilaments. Both these tests hence show that E. coli enterotoxin-induced diarrhoea results in absorption and permeability changes.

Fluid restriction does not improve the outcome of acute meningitis.

The objective of this prospective study was to examine the effect of fluid restriction on body water and the outcome of children with acute meningitis. Fifty consecutively hospitalized children with acute meningitis, divided into two groups (A, without hyponatremia; and B, with hyponatremia), were randomly assigned to receive either normal maintenance (M) or restricted (R subgroup) (65 to 70% of M subgroup) fluids during the first 48 hours. Total body water, extracellular water (ECW), serum and urinary sodium and plasma and urinary osmolality were measured at admission and after 48 hours. In both groups children receiving restricted fluids showed a significant decrease in the mean total body water and ECW whereas body water remained unchanged in those on maintenance fluids. Children having an ECW reduction of 10 ml/kg or more in 48 hours had a significantly lower intact survival (10 of 28, 36%) than those with < 10 ml/kg or no reduction of ECW (15 of 22, 64%) (P < 0.05). The mortality was also higher in the former (7 of 28, 25%) than in the latter (2 of 22, 9%). On multiple stepwise regression analysis, ECW volume at admission (partial r2 0.20), ECW loss in 48 hours (partial r2 0.13) and plasma osmolality at admission (partial r2 0.22) were significantly related to outcome. We conclude that fluid restriction does not improve the outcome of acute meningitis. Indeed a decrease in ECW volume at 48 hours increases the likelihood of adverse outcome.

Calcium and protein kinase C play an important role in Campylobacter jejuni-induced changes in Na+ and Cl- transport in rat ileum in vitro.

The pathophysiological mechanism of Campylobacter jejuni (enterotoxigenic) induced secretory diarrhoea remains least understood. To investigate the mechanism(s) involved, the unidirectional fluxes of Na+ and Cl- were measured across the C. jejuni live culture infected and control (non infected) rat ileum (unstriped), in vitro by Ussing technique under short circuit conditions, in the presence or absence of: Ca2+ ionophore A23187 (5 microM), 1-verapamil (100 microM), calmodulin (CaM) antagonist W-7 (100 microM), dantrolene (25 microM), protein kinase C (PKC) activator PMA (100 ng/ml) and H-7 (60 microM), selective inhibitor of PKC. There was net absorption of Na+ and enhanced Cl- secretion in infected animals while in control animals there was net absorption of Na+ and marginal secretion Cl-.Ca2+ ionophore A23187 mimicked the effects of C. jejuni infection whereas 1-verapamil had significant antisecretory effect on Na+ and Cl- secretion in infected animals. In vitro measurement of undirectional 45Ca fluxes in Ussing chamber experiments revealed net absorption of Ca2+ in infected rat ileum as compared to net secretion of Ca2+ in control rat ileum. These observations clearly indicate that there is increased stimulation of Ca2+ uptake from extracellular milieu to the enterocytes during C. jejuni-induced diarrhoea. The intracellular calcium levels (Ca2+]i (as measured by fluorescent probe Fura-2AM) were found to be raised significantly (P < 0.0001) in enterocytes isolated from C. jejuni infected ileum as compared to the enterocytes from control ileum. The observed increase in [Ca2+]i in enterocytes isolated from C. jejuni live culture supernatant treated rat ileum further shows the involvement of enterotoxin in diarrhoeal process. Dantrolene decreased significantly C. jejuni-induced net Na+ and Cl- secretion but it could not reverse it to absorption suggesting the partial involvement of Ca2+ mobilised from intracellular stores in mediating secretion. W-7 failed to inhibit the C. jejuni-induced net Na+ and Cl- secretion. In addition the CaM activity estimated in intestinal microvillar core remained same in both the control and C. jejuni infected animals. This indicates that C. jejuni-induced diarrhoea is not mediated through the activation of Ca(2+)-CaM complex pathway of the Ca2+ messenger system. The PKC activator PMA, induced net secretion of Na+ and Cl- in the control animals but it could not enhance further the C. jejuni-induced Na+ and Cl- secretion, suggesting that there is overlapping effect of PMA and C. jejuni live culture infection.(ABSTRACT TRUNCATED AT 400 WORDS)

Changing pattern of childhood poisoning (1970-1989): experience of a large north Indian hospital.

The epidemiology of acute poisoning in children aged 0-15 years hospitalized between 1970-1989 was retrospectively investigated. Two hundred and seventeen children were admitted during this period with 134 in 1980-1989 vs 83 in 1970-1979. Two distinct patterns were observed: accidental poisoning in under 11's and adult pattern and self poisoning in children over 11's. More children belonged to urban areas (72.3%) as compared to rural areas. In both decades more than half of children belonged to middle income group followed by lower income group and least to upper income group. The overall mortality was low (12.5%), with majority of deaths (78%) occurring in older children. The incidence of kerosene ingestion was noticed to have dropped by more than half between 1980-1989 as compared to 1970-1979 (14.9% vs 42%). The study highlights the unacceptable high rate of preventable accidental poisoning in young children and suicide and parasuicide in older children (11-15 years age group).

Benign cutaneous polyarteritis nodosa in children below 10 years of age--a clinical experience.

OBJECTIVE: To report 10 children younger than 10 years of age with benign cutaneous polyarteritis nodosa (BCPAN). METHODS: Ten children aged 1.25-10 years (mean 4.7 years; M:F = 7:3) were admitted with an unusual vasculitis. The clinical features, laboratory investigations, treatment and follow up data were analysed. RESULTS: Clinical features of these patients included: fever (10), peripheral gangrene (eight), livido reticularis (four), ulceration, nodules and vesiculobullous lesions alone or in combination (10), black necrotic patches over limbs and trunk (three), and arthralgia or swelling of large joints (seven). Cryoglobulinaemia was transient in three children, lasting for eight months in one of them. Histopathology of the skin lesions revealed vasculitis of small and occasionally medium sized blood vessels in nine of the 10 children. Possible association of BCPAN was noted with diphtheria-pertussistetanus immunisation (one), drugs (two), streptococcal infection (two), wasp sting (one), and falciparum malaria (one). The clinical course was interspersed with remissions and exacerbations. Response to corticosteroids alone occurred in seven patients, while three children needed cytotoxic drugs in addition. In a follow up of 5.6 years (mean) no evidence of systemic involvement was noted. CONCLUSIONS: A rare form of vasculitis, BCPAN, is reported in children. The features that distinguished our patients from those reported earlier were onset in the first decade of life and higher incidence of peripheral gangrene.

Impairment of Na+,K(+)-ATPase activity following enterotoxigenic Campylobacter jejuni infection: changes in Na+, Cl- and 3-O-methyl-D-glucose transport in vitro, in rat ileum.

Unidirectional fluxes of Na+, Cl- and 3-O-methyl-D-glucose (3-MG) were measured in vitro across Campylobacter jejuni live culture-infected and control rat ileal short-circuited tissues by the Ussing Chamber technique. Net secretion of Na+ and enhanced secretion of Cl- ions was observed in the infected animals (P < 0.001, n = 6) as compared to the net absorption of Na+ and marginal secretion of Cl- ions in the control animals. There was a significant decrease in the mucosal-to-serosal fluxes of 3-MG in C. jejuni-infected rat ileum. The specific Na+,K(+)-ATPase activity when measured biochemically in the membrane-rich fraction of enterocytes was found to be significantly lower (58%) in the infected group as compared to the control group (P < 0.001). Our results therefore suggest that infection with an enterotoxigenic C. jejuni inhibits the Na+,K(+)-ATPase activity in rat enterocytes. The impairment of Na+,K(+)-ATPase activity thus appears to induce a secondary change in Na+,Cl- and 3-MG transport in vitro in rat ileum.

Effect of Escherichia coli enterotoxins on macromolecular absorption.

Macromolecular absorption of gliadin, a wheat protein and alpha lactalbumin, a milk protein was evaluated in control and Escherichia coli enterotoxin (heat-stable, heat-labile, and both heat-stable and heat-labile enterotoxin) treated mice. The peak concentration of gliadin and lactalbumin was two hours and three hours after their ingestion, respectively. There was also a significant increase (p < 0.01) in the absorption of both the proteins in all the three toxin treated groups compared with the control group. These results suggest that intestinal permeability and macromolecular absorption changes after E coli infection.

Sonography in pyogenic meningitis.

In this prospective study to evaluate usefulness of ultrasonography for early diagnosis and monitoring of complications of acute pyomeningitis, we performed serial sonographic examinations of skull in 50 infants (with open fontanelle) with proven pyomeningitis. One or more abnormal sonographic findings were detected in 32 infants. These were echogenic sulci (26%), ventriculomegaly with some or other complication (26%), brain abscess (20%), ventriculitis (14%), subdural effusion (6%) and cerebral edema (10%), and were detected mostly after the first week of illness. Ultrasonographic findings were in complete agreement with CT scan diagnosis of ventriculomegaly, ventriculitis, solitary brain abscess and cerebral edema. However, sonography missed cases of subdural effusion (2 out of 5), multiple brain abscesses (1 out of 2), and cerebral infarction (all the four), which were detected on CT Scan. Serial sonographic findings were useful in documenting progressive increase in ventricular size in all the 13 infants with ventriculomegaly and monitoring response to anti-edema therapy in 5 infants with cerebral edema. Sonography is a useful tool for diagnosis of complications of pyomeningitis after the first week of illness, and for monitoring the progress of ventriculomegaly.

Involvement of intracellular calcium stores in Giardia lamblia induced diarrhoea in mice.

The transmucosal fluxes of Na+ and Cl- were studied in Giardia lamblia-infected mice in the presence or absence of dantrolene (1-(5(p-nitrophenyl)furfurilidene-amino) hydantoin sodium hydrate). There was net secretion of Na+ and Cl- in infected animals, while in control animals there was net absorption of these ions. The addition of dantrolene resulted in significant net increase in absorption of Na+ and Cl- in control and experimental groups. Further, mouse intestinal epithelial cells were labelled with [32P]Pi and then treated with G. lamblia trophozoites and their excretory secretory products separately. The optimum time for inositol triphosphate formation was 15 min in control enterocytes as well as in treated enterocytes. A plateau was formed at higher concentrations. Since raised inositol triphosphate levels mobilize Ca2+ from intracellular stores and dantrolene traps Ca2+ within intracellular calcium stores, the present study thus suggests that intracellular calcium stores are involved in G. lamblia-induced diarrhoea in mice.

Clinical signs of pneumonia in infants under 2 months.

To determine clinical signs that can predict pneumonia (confirmed by radiography) in infants under 2 months of age, 101 infants with pneumonia and 150 with an upper respiratory infection (but not pneumonia) were studied. Ten infants with pneumonia and 15 with an upper respiratory infection did not have the cough and/or difficult (or rapid) breathing that are recommended as 'entry criteria' by the World Health Organisation (WHO). The remaining infants met WHO entry criteria; in them sensitivity and specificity of respiratory rate > or = 60/min and/or severe chest indrawing to diagnose pneumonia was 85% and 97% respectively. Addition of four non-specific signs (stopped feeding well, looked sick, temperature < or = 38 degrees C, and abdominal distension) to respiratory rate > or = 60/min and/or chest indrawing for case identification resulted in a 7% gain in sensitivity but 22% loss of specificity. Addition of nasal flaring improved the sensitivity by 6% without loss of specificity. However, the non-specific signs were the only clue to diagnosis in five infants weighing < or = 2500 g. At age < 7 days, a weight < or = 2500 g and cyanosis were associated with significantly higher risk of mortality. These findings support the use of a respiratory rate > or = 60/min and/or chest indrawing for identification of pneumonia, and suggest addition of nasal flaring to the criteria for case identification in infants under 2 months with cough and/or difficult or rapid breathing.

Co-existence of oblique pinnae and congenital heart disease.

The paper reports a syndrome in which oblique placement of one or both the pinnae on face was found to co-exist with congenital anomalies of heart like VSD, PDA and Tetralogy of Fallot, etc. Although clinically discernible in 90% of the subjects, objective evidence of obliquity of pinna was documented by photogrammetry. The values for the ear inclination in subjects categorized clinically as normally placed pinna were 7.9 degrees +/- 3.39 degrees with range 2 degrees-17 degrees. In contrast, subject where the pinna was clinically categorized as oblique had mean AEI 16.5 degrees +/- 5.81 degrees with a range 5 degrees-33 degrees. Eighteen of the 20 subjects with oblique pinna were demonstrated to have some congenital anomaly of heart as indicated by clinical and echocardiographic examination. In contrast, in subjects with normally placed pinna only 3 out of 34 possessed clinical heart defects. Presence of oblique pinna indicates a thorough search for undetected heart defects.