Pediatrics, Pediatricians and Child Care : Based on 16th Dr. K. C. Chaudhuri and Dr. Amala Chaudhuri Oration, on 15th October 2023.

Medical problems of children and their differences from adults have been mentioned in the ancient texts. Important contributions to medicine, including treatment of diseases of children were made by Greek and many scholars from middle East countries in 10th century. Pediatrics became widely recognized in Europe and USA during early 19th century and a number of children's hospitals were established in major cities. With technological advances, pediatric subspecialties also developed. In India, pediatrics was recognized around 1950s and thereafter, gradually progressed. Pediatric specialties came up in 1970s and became well established during 2020s. Pediatricians are regarded as doctors treating sick children. Pediatric specialists have the responsibility of providing tertiary care to patients with complex systemic diseases and critical care. In our country having a huge underprivileged population, pediatricians need to play a wider role and aim to provide comprehensive care that would lead to optimum development for every child. They should be aware of child rights, widely prevalent child abuse and exploitation and legal protective mechanisms, and attempt to tackle these issues in association with other agencies and organizations working for child welfare.

Outcome of acetabulum fractures treated with open reduction and internal fixation through Kocher-Langenbeck Approach: A retrospective study.

BACKGROUND: Complex anatomy of acetabular fracture is quite challenging for the orthopedic surgeons. Many Acetabular fracture fixation approaches have been used for a long time to treat different fracture patterns of acetabulum. Kocher-Langenbeck Approach (K-L approach) of acetabulum fracture is usually used by most of orthopedic surgeons. In this retrospective study, we evaluated the clinical and functional outcome of subtypes of acetabulum fractures treated with K-L approach. Assessment of Intra and postoperative complications of subtypes of acetabulum fractures was also done. METHOD: Eighty patients (48 men and 32 women) were included in this retrospective study with a mean follow-up period of 2.6 years. Fractures were classified according to Letournal and Judet classification. K-L approach was performed in all these patients. Post operative reduction, Radiological outcome was quantified using Matta's criteria while the functional outcome was assessed according to Merle d'Aubigné and Postel scoring system. Postoperative complications were evaluated. RESULTS: The mean age of a total of 80 cases was 43.64 ±â€¯13.24 year. The type of fracture was found to be significantly associated with concentric/non-concentric reduction (p = 0.003) and with post op reduction (p = 0.005). The post operative reduction was found to be significantly associated with radiological (p < 0.001) and functional outcome (p < 0.001) at one year post op. The type of fracture was found to be significantly associated with radiological outcome (p < 0.001) while non-significantly found to be associated with functional outcome at 1 year (p = 0.050). The type of fracture was found to be significantly associated with post op complications (p = 0.003) and with arthritis (p = 0.001). CONCLUSION: K-L approach is a multifaceted and convenient approach for treating acetabulum fractures. Type of fracture and post-operative reduction are key factors for a satisfactory outcome. Transverse with posterior wall fracture has the worst prognosis.

Posttransplant Lymphoproliferative Disorder: Experience from a Pediatric Nephrology Unit in North India.

Posttransplant lymphoproliferative disorder (PTLD) is reported in 1%-3% among pediatric renal allograft recipients. We report the experience of PTLD among pediatric renal allograft recipients at a pediatric nephrology center in North India. Four cases of PTLD were identified from among records of 95 pediatric renal allograft recipients over a period of 21 years. Constitutional and localizing symptoms were present in three patients each. The diagnosis was suggested on positron emission tomography in three patients and confirmed by histopathology in all. Sites affected included tonsils, cervical lymph nodes, duodenum, and para-aortic lymph nodes in one patient each. The lymphocytic infiltrate was polymorphic in three patients and monomorphic in one. Immunostaining suggested B-cell origin in all patients. There was evidence of Epstein-Barr virus infection in only one patient. The patients were successfully managed with reduction of immunosuppression (in all), rituximab (in 3), and excision of affected tissue (in 1). Over a follow-up period of 30-88 months, there were no episodes of disease recurrence or allograft rejection, and renal function was preserved.

Child Sexual Abuse: Management and Prevention, and Protection of Children from Sexual Offences (POCSO) Act.

Child Sexual Abuse is an alarming reality and is being increasingly reportedin India as well as globally. Pediatricians and allied medical professionals are often the first point of contact with abused children and their families. They have a key role in detecting Child Sexual Abuse, providing immediate and long-term care and support to the victims and their families. India has adopted the Protection of Children from Sexual Offences Act (POCSO) in 2012. It is a comprehensive law on sexual abuse, which expands the scope and range of forms of sexual offences, makes reporting of abuse mandatory and defines guidelines for the examination of victims. Pediatricians and health care professionals need to acquire necessary expertise for clinical evaluation of child sexual abuse, and its prevention, management and reporting.

Efficacy of Task Oriented Exercise Program Based on Ergonomics on Cobb's Angle and Pulmonary Function Improvement in Adolescent Idiopathic Scoliosis- A Randomized Control Trial.

INTRODUCTION: Scoliosis is lateral curvature of the spine greater than 100 accompanied by vertebral rotation. The prime risk factors for curve progression are a large curve magnitude, skeletal immaturity and female gender. The curve progression can be recorded by measuring the curve magnitude using the Cobb's method on radiographs. AIM: To assess the effect of task oriented exercises based on ergonomics on Cobb's angle and pulmonary functions on one year outcome of Adolescent Idiopathic Scoliosis(AIS) (defined as curves < 150 for thoracolumbar region and < 200 for thoracic region). MATERIALS AND METHODS: A total of 36 patients were enrolled in the study and 18 patients in each group (experimental and control group) were allocated randomly. The subjects in control group underwent spinal strengthening exercises, active self-correction and breathing exercises, whereas subjects in the experimental group followed task oriented exercises based on ergonomics in addition to exercises for conventional group for one year. Chi square test was used to compare the categorical/ dichotomous variables between the groups. Unpaired t-test was used to compare continuous variables between the groups at pre and post intervention. Paired t-test was used to compare the changes in continuous variables from pre to post intervention within the group. RESULTS: Forced Vital Capacity (FVC) was found to be significantly (p=0.001) higher in experimental group (2.68±0.37) than control group (2.20±0.41) at post-intervention. Force Expritatory Volume 1 (FEV1) (p=0.01) and Vital Capacity (VC) (p=0.002) were also found to be significantly higher in experimental group compared to control group at postintervention. Also, there was significant (p=0.001) mean reduction in Cobb's angle from pre to post intervention in both the groups being higher in Experimental group than control group. CONCLUSION: The task oriented exercise protocol benefited patients with AIS which had a significant improvement of their pulmonary functions and Cobb's angle.

Evaluation of the association between a single-nucleotide polymorphism of bone morphogenetic proteins 5 gene and risk of knee osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic degenerative disorder probably affected by both genetic and environmental causes. Bone morphogenetic proteins (BMPs) are bone-derived factors that can induce new bone formation. Single-nucleotide polymorphisms (SNPs) of BMP5 gene alters the transcriptional activity of the BMP5 promoter that has been involved in OA susceptibility. This case-control study investigated the association of rs1470527 and rs9382564 SNP of BMP5 gene with susceptibility to knee OA (KOA). MATERIALS AND METHODS: A total of 499 cases with radiographic KOA and 458 age- and sex-matched healthy controls were enrolled. Venous blood samples were obtained from all the cases as well as controls for polymerase chain reaction-restriction fragment length polymorphism. RESULTS: The genotype distribution for rs1470527 and rs9382564 SNP was significantly different in cases and controls (P < 0.0001). Within both the SNPs of BMP5 gene, genotype CT and TT were significantly (P < 0.0001) associated with KOA as compared to the CC genotype. T allele of both the studied SNP was significantly associated with KOA (P < 0.0001). The allele frequencies of rs1470527 were 0.56(T) and 0.44(C) in cases and 0.33(T) and 0.67(C) in controls and in rs9382564 were 0.57(C) and 0.43(T) in cases and 0.71(C) and 0.29(T) in controls. Further in relation with clinical severity of OA, we observed signification association of TT genotype with both visual analog scale (P < 0.0001) and Western Ontario and McMaster Universities score (P < 0.05). CONCLUSION: Our results indicate significant association of rs1470527 and rs9382564 polymorphism of BMP5 gene with KOA.

Pressure ulcer management in paraplegic patients with a novel negative pressure device: a randomised controlled trial.

OBJECTIVE: A randomised controlled trial to compare negative pressure wound therapy (NPWT) using our innovative negative pressure device (NPD) and the standard pressure ulcer (PU) wound dressing of in traumatic paraplegia patients. METHOD: This study was conducted in the Department of Orthopaedic Surgery at King George's Medical University, Lucknow, India. Traumatic paraplegia patients with sacral pressure ulcers of stage 3 and 4 were randomised into two groups, receiving either standard wound dressings or NPWT with NPD. The outcomes monitored were length, width (surface area), depth of PU, exudates, discharge, tissue type (necrotic, slough and red granulating tissue), and cost-effectiveness during 0 to 9 weeks follow-up. RESULTS: Length and width were significantly (p<0.01) decreased in NPWT group as compared with standard care group at week 9. At weeks 1, 2 and 3, depth was significantly (p<0.05) higher in NPWT group, whereas at week 9 a significant reduction (p=0.01) was observed. Exudates were significantly (p=0.001) lower in NPWT group at weeks 4 and 9. Conversion of slough into red granulation tissue was significantly higher in NPWT group (p=0.001). Discharge became significantly (p=0.001) lower in NPWT at week 2 and no discharge was observed after week 6. In all parameters, decrease was larger in NPWT group compared with standard care, which was significant for exudates type (p=0.03) and tissue type (p=0.004). CONCLUSION: Our NPD is better than standard wound care procedures and cost-effective for management of PU.

Right to health for children.

India is a signatory to UN Convention on Child Rights but the allocation of funds and interventions to address health problems have been insufficient. A rights-based rather than a welfare approach is needed to realize child rights, of which health and education are crucial. The health needs of the newborn (survival), infant (vaccinations, nutrition) and preschool child (infections, development) require particular attention. Health care delivery systems should be made fully functional, programs properly implemented, and accountability ensured at all levels. Basic curative services must be provided free for all children. Functional health literacy should be provided to the underprivileged.

Perineal antropylorus transposition for end-stage fecal incontinence in humans: initial outcomes.

BACKGROUND: Technical feasibility of perineal antropyloric valve transposition to reconstruct a severely damaged incontinent anal sphincter or to replace an excised anorectal sphincter has been reported previously. OBJECTIVE: This study aimed to document the follow-up results of patients who underwent successful perineal antropyloric valve transposition for end-stage fecal incontinence. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Seventeen patients underwent the procedure. Eight patients had replacement (group 1) and 9 patients had augmentation (group 2) of the anal sphincter. Two patients in group 1 with early graft-related complications were excluded from further analysis, because they had the grafts excised. MAIN OUTCOME MEASURES: The primary outcome measures were anatomical integrity and functional status of the graft in the perineum, fecal incontinence scores, and quality-of-life scores (SF-36) over a median follow-up of 18 months. RESULTS: The transposed grafts had a definite tone on digital examination, were well visualized on perineal MRI, showed high-velocity vascular inflow on Doppler ultrasound study, and good vascularity on celiac CT angiography. Anal manometry showed a significant (p = 0.03) rise in the postoperative resting neosphincter pressures with good retention of barium proximal to pyloric valve on distal loopogram. The postoperative St Mark incontinence score improved in both groups and was significantly better in group 2 than in group 1. There was significant improvement in postoperative physical and mental component scores in both groups with higher scores in group 2 than in group 1 on follow-up. LIMITATIONS: A longer follow-up with a larger sample size is required. CONCLUSIONS: Antropyloric valve transposition can be used effectively for a selected group of patients with end-stage fecal incontinence. Patients undergoing anal sphincter augmentation have better outcomes in comparison with those having an excised sensate anorectum.

Diagnostic and prognostic role of MRI in spinal trauma, its comparison and correlation with clinical profile and neurological outcome, according to ASIA impairment scale.

AIMS AND OBJECTIVES: To evaluate the role of magnetic resonance imaging (MRI) as a non-invasive diagnostic tool in patients with acute and chronic spinal trauma and to compare and correlate the MRI findings with those of patients' clinical profile and neurological outcome according to ASIA impairment scale to assess prognostic and clinical value of MRI. MATERIALS AND METHODS: Sixty two patients of spinal trauma formed the study group in a prospective fashion. The patients undergoing MR imaging and magnetic resonance images were analyzed and correlated with findings on neurological examination according to American Spinal Injury Association (ASIA) impairment scale (AIS) at the time of MRI examination and subsequently at sub-acute interval to assess neurological outcome. STATISTICAL ANALYSIS: Sample profile was described in terms of 95% confidence limit and proportion. To describe strength of association between extent of spinal cord injury and outcome, odd's ratio, bivariate and multi variant analysis, was used. Pearson's chi square (χ) (2) statistics was applied to test the association between two categorical variables. Data were analyzed using statistical software package, STATA 9.2 and the difference was considered to be significant if 'P' value was <0.05. OBSERVATION AND RESULTS: The cord edema without hemorrhage was the most common MR finding (41.5%). The others were sizable focus of hemorrhage within the cord (33%), epidural hematoma (5.0%), and normal cord (26%). Majority of MR findings correlated well with clinical profile of the patient according to ASIA impairment scale. This study demonstrated that patients with presence of sizable focus of haemorrhage had larger cord edema and more severe grade of initial ASIA impairment scale( AIS) with poor recovery at follow up (P=0.032).Improvement in upper extremity was more than lower extremity. Severe cord compression was also associated with poor neurological outcome; however it was not statistically significant (P=0.149). CONCLUSIONS: With this study the authors concluded that various MRI findings in acute spinal cord injury correlated well with the initial clinical findings and on follow-up according to ASIA impairment scale. MRI is useful for initial diagnosis of acute spinal cord injury and its prognostication for predicting neurological recovery.

Outcome of pediatric renal transplantation in north India.

We report our experience and long-term outcome of pediatric renal transplantation at a referral center in New Delhi. During 1995-2008, 45 transplants were performed in 43 patients at a mean age of 13.3 ± 4.0 (range 3.8-18) yr. The chief causes for ESRD were reflux nephropathy, obstructive uropathy, vasculitis, renal dysplasia, and focal segmental glomerulosclerosis. Most (91.1%) donors were living related. Post-transplant immunosuppression comprised prednisolone, a calcineurin inhibitor and azathioprine or MMF. AR and CR were seen in 14 (31.1%) and 12 (26.7%) allografts, respectively. Predictors of CR were unsatisfactory compliance and multiple episodes of AR (p = 0.002 each). Urinary infections (n = 13), septicemia (4), tuberculosis (4), CMV disease (7), viral hepatitis (7), and pneumonia (3) were important causes of morbidity. Two patients each had lymphoproliferative disease and new-onset diabetes. There were eight (17.8%) graft losses and six (14%) deaths. The one-, five- and 10-yr graft survivals were 91.1%, 80.4% and 75.1%, respectively; the mean graft survival was 119.4 ± 8.38 months. The respective patient survivals were 95.3%, 87.9%, and 76.9% at one-, five- and 10 yr. Our results affirm that despite scarcity of resources and frequent infections, long-term outcomes of pediatric renal transplantation are highly satisfactory.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.