Blood Pressure Variation with Altitudes in Children: A Cross-Sectional Observational Study from Himalayan Hills.

OBJECTIVES: We aimed to evaluate blood pressure (BP) in Indian children who had similar demographic characteristics but hailed from different altitudes. METHODS: BP of school going children, aged 5 to 12 years, at five different locations varying in altitude (near sea level: n = 425; 2000 feet: n = 244; 4000 feet: n = 248; 6000 feet: n = 242 and 8000 feet: n = 250) was measured in a mountainous district in Himalaya. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded by aneroid sphygmomanometer in the sitting posture using a calibrated instrument and four trained resident doctors. The average of three readings was taken. RESULTS: Of the 1229 children whose data were analyzed, 50.4% were boys. SBP showed a progressive rise from 99.5 (4.00) mmHg [mean (standard deviation)] at near sea level to 106.7 (4.17) mmHg at 8000 feet. Similarly, DBP showed a rise from 60.1 (3.67) mmHg to 66.8 (4.58) mmHg over the same altitude range. Analysis of covariance for BP variation with altitude, with age as covariate, indicated a modest but statistically significant rise in both SBP and DBP with altitude. Higher BP values was noted among children residing at higher than at lower altitude (0.8% at sea level to 18.8% at 8000 feet). Correlations between SBP and DBP values and height and weight, though positive and significant at p < 0.01 level, were weak. CONCLUSIONS: These data will help in correct interpretation of BP readings in children residing at high altitude.

Leave against Medical Advice in Children: Rural Indian Perspective.

OBJECTIVES: To determine the burden and etiological factors of leave against medical advice (LAMA) in Indian children. METHODOLOGY: In this prospective study, legal guardians of 528 patients who took the decision of LAMA were interviewed (using structured question answers based multi-option) and data were captured over a period of 16 months. The resultant database was analyzed using standard statistical methods. RESULTS: About 6.12% of childhood LAMA cases were dealt out of total pediatric admission including newborns. Neonatal preponderance noted in cases of LAMA from intensive care unit (ICU; 57.14%, p < 0.05). The overall male (n = 293) to female (n = 235) ratio in this study was 1.25:1. Number of LAMA patients was higher from rural area (83.33%), mostly admitted in ICU (93.65%, Pearson's chi-squared test, p < 0.05). Higher proportion (29.47%) of patients with infection availed LAMA from neonatal age group but overall LAMA patients fall under category of respiratory disorders (22.35%). Interest of the domestics issues other than suffering child was considered primary during LAMA for those admitted in ward as compared with ICU patients [odds ratio (OR): 1.73, CI: 1.02-2.94, p < 0.05]. ICU patients were reportedly to be taken to private health care facility (OR: 1.93, CI: 1.06-3.49, p < 0.05). Duration of stay before taking LAMA from ward was <7 days (85.59%, OR: 0.19, CI: 0.11-0.35, p < 0.05). Upper-lower socio-economic class attributed financial constraint as the main reason for LAMA (Pearson's chi-squared test, Chi-square value: 152.23, p < 0.05). CONCLUSIONS: This study tried to elucidate the determinants of childhood LAMA in rural Indian setting.

Functional status of Indian children with juvenile idiopathic arthritis.

Background and Objectives: The functional disability status of Indian children with juvenile idiopathic arthritis is unidentified. In this cross-sectional study functional capacity of 60 juvenile idiopathic arthritis patients was assessed by the Childhood Health Assessment Questionnaire. Methods: A total of 60 juvenile idiopathic arthritis patients aged ranges from 1 to 12 years were recruited from a teaching hospital in eastern India. A childhood health assessment questionnaire was used to assess the functional health of children. Pain, patient's/parent's global assessment of general well-being, and physician's global assessment were assessed. Results: Childhood health assessment questionnaire disability index for oligoarticular juvenile idiopathic arthritis differed significantly from polyarticular juvenile idiopathic arthritis (P < 0.001), systemic-onset juvenile idiopathic arthritis (P = 0.018) and undifferentiated juvenile idiopathic arthritis (P < 0.001). There was a good to a strong positive correlation between the childhood health assessment questionnaire disability index with pain score, patient's/parent's global assessment score, and physician global assessment score for the total juvenile idiopathic arthritis cohort. regarding juvenile idiopathic arthritis subtypes, significant correlations were noted between the childhood health assessment questionnaire disability index with the patient's/parent's global assessment and physician's global assessment (except for enthesitis-related arthritis). Conclusions: Assessment and documentation of the functional health status of juvenile idiopathic arthritis patients will improve the management of the disease.

Newborn joint mechanics.

INTRODUCTION: We aimed to evaluate joint mechanics in newborn by goniometric assessment of major joints in healthy babies born at different gestational ages (GAs). MATERIALS AND METHODS: An institution based observational study was carried out on healthy newborn babies within two days of birth. Study subjects were born at 28-41 completed weeks of gestation. The major joints of upper and lower limbs were assessed with manual goniometer for joint angles in relation to specific passive movements and range of motion (ROM) calculated where applicable. All measurements were made by a single observer with careful consideration of plane of movement and axes involved. Strength of association between joint angles and GA was quantified by Pearson's r coefficient. RESULTS: Six major joints (shoulder, elbow, wrist, hip, knee, and ankle) were evaluated on either side in 433 babies. No significant differences were found between male and female babies and left or right side of the body. For most joints, a secular declining trend of joint angle or ROM was noted with good to strong inverse correlation with GA. The strongest associations were for flexion-extension ROM and adduction-abduction ROM at shoulder, palmar flexion at wrist and dorsiflexion at ankle joint with r values of -0.76, -0.75, -0.75, and -0.75, respectively. CONCLUSIONS: The reading of a specific joint angle in the newborn infants was found to be dependent on GA. Precise calibration of gestation appropriate joint angles had laid down the foundation for functional assessment of multimodal joint mechanics.HighlightsEvaluation of newborn joint angles require stringent attention toward the plane and axis of the particular joint movement being assessed.Major joint angles and range of motion in newborn infants were observed to follow a secular declining trend according to the gestational age.Precise estimation of gestation appropriate joint angle will be helpful to understand the mechanics of musculoskeletal medicine in newborn.

Economic Burden of Juvenile Idiopathic Arthritis in India.

BACKGROUND: Published Indian studies on the economic burden of juvenile idiopathic arthritis (JIA) are lacking. METHODS: A prospective observational study recruited pediatric patients aged from 1 to 12 years with JIA in the pediatric rheumatology clinic of a public sector tertiary care hospital. Direct healthcare costs and indirect costs for transportation, accommodation of the caregivers, and productivity loss for work absenteeism were assessed. RESULTS: The proportions of direct annualized cost assessed in 60 patients (mean (SD) age 8.46 (2.24) year) spent on outpatient visits, blood tests, imaging investigations, other tests, medications and hospitalization were 0.85%, 12.8%, 9.0%, 2.9%, 41.7% and 32.7%, respectively. Direct healthcare costs for blood tests and medicine were lowest in oligoarticular JIA and highest in systemic onset JIA and (P=0.043 and 0.001 respectively). The direct and indirect costs were higher with the use of biologic agents (n=9) than in those without (n=51). CONCLUSION: JIA imposes considerable economic burden with the largest share attributable to medicines, and maximum in those with systemic onset JIA.

Serum Ferritin as a Diagnostic Biomarker for Severity of Childhood Sepsis.

OBJECTIVE: To explore association between serum ferritin and severity of sepsis among children, and relate levels to the final outcome. METHODS: This observational study was conducted in a tertiary care hospital between I February and 30 July, 2019. Serum ferritin level was estimated in children (age 6 months to 12 years) suffering from sepsis, irrespective of the probable etiology. Children with hemoglobinopathies, autoimmune diseases, previous blood transfusion, severe acute malnutrition, hemophagocytic lymphohistiocytosis and chronic hepatitis were excluded. The ferritin level was measured sequentially at pre-defined stages of illness viz., sepsis, severe sepsis, septic shock and multiorgan dysfunction syndrome (MODS). Association between serum ferritin and severity of sepsis was analyzed, and ferritin level was related to the final outcome of death or recovery by receiver operating characteristic (ROC) curve analysis. RESULTS: The study group included 47 children with sepsis who progressed to a state of MODS; 32 recovered from MODS. Significant differences in serum ferritin level were observed with severity of sepsis. There was clear demarcation of ferritin levels between sepsis severity stages. The proportion of death among the 47 MODS cases was 31.9% (95% CI 18.6 - 45.2%). ROC analysis in the MODS group indicated that serum ferritin >1994.3 ng/mL predicts mortality (AUC 0.73 [95% CI 0.58-0.85]) with sensitivity 66.7% [95% CI 38.4-88%] and specificity 100.0% [95% CI 89.1-100%]. CONCLUSIONS: There is clear demarcation of serum ferritin levels that can help differentiation of sepsis severity stages in children with sepsis. There is no such demarcation between survivors and non-survivors in MODS cases.

Evolution of clinical method for new-born infant maturity assessment.

In the routine practice of neonatology, differentiating preterm premature new-born from small-for-date (SFD) new-born infant is an essential aspect to anticipate different clinical scenarios and monitor accordingly. Clinical assessment of new-born maturity is an invincible tool in resource poor areas for the purpose, without any prior investment. Over the past decades, clinical method for new-born infant maturity assessment has evolved intricately. From defining prematures with a mere statement of birth weight to clinical assessment of new-born as per gestational age with a comprehensive scheme based on neural and physical maturity characteristics of a new-born, clinical method for new-born maturity assessment has evolved substantially to the present where we stand. A complete review on the evolutionary history of clinical method for new-born infant maturity assessment will enable researchers in this field to get acquainted with the trend of past research work in accordance to the recent advancement all over the world. In the process, the lacunae still present in this area of study can be spotted which will invite new research proposals. Looking into the recent context, clinical method for assessing new-born infant maturity is making further forward shift with an attempt to quantify neuromuscular maturity criteria with further precision and incorporation of additional criteria."What is known - What is New" (Authors' summary)What is knownNeuro-muscular and external physical characteristic assessment together has greater significance for evaluating new-born infant's maturity as per gestational age over using individual one of them.Evaluation of brain maturity through passive muscle tone assessment of new-born infants with different maneuvers has the imperative role in determining new-born infant maturity.What is newClinical method for determining new-born infant maturity as per gestational age is being made explicit with the incorporation of criteria like feeding behavior of the new-born and objective assessment of anthropometric parameters, beside neuro-muscular and external physical characteristics evaluation.Neuro-muscular maturity can be quantified further with absolute values or closer range of values of different maneuvers and signs used in the clinical method for evaluating new-born infant maturity as per gestational age with more precision.