Study of Hematological Alterations in Malaria at a Tertiary Health Care Center of South Gujarat, India

Background: Malaria is a disease with a great global burden. It is one of the most prevalent parasitic infection common intropical, subtropical countries, particularly Asia and Africa. Malaria causing plasmodia is parasites of blood and hence induceshematological alterations. The hematological changes that have been reported to accompany malaria include anemia,thrombocytopenia, leukocytosis as well as leukopenia, mild-to-moderate atypical lymphocytosis, monocytosis, eosinophilia,and neutrophilia. Hence, the present study is undertaken to evaluate the various hematological parameters affected in malariaand to observe the variations, if any, in Plasmodium falciparum, Plasmodium vivax, and mixed infections.Materials and Methods: The present study was carried out in the Department of Pathology at Tertiary Health Care Centerof South Gujarat from August 2018 to October 2018. A total of 480 smear-positive malaria cases were analyzed and varioushematological parameters were studied.Results: Out of 480 smear-positive cases, P. vivax was positive in 77% of cases, P. falciparum was positive in 22% of casesand mixed infection in 1% of cases. Most of the cases were seen in the age group of 21–40 years. Anemia was seen in 53.1%of cases. Normocytic normochromic blood picture was the most common type in anemic patients (46.6%). Thrombocytopeniawas seen in 84.58% of the patients. Out of which, 75.86% were affected by P. vivax, 23.15% were affected by P. falciparum,and 0.98% were affected by the mixed infection. About 28.75% of cases showed hematological features of leukopenia, and5.2% of cases were having leukocytosis.Conclusions: Various hematological findings can help in early diagnosis of malaria which is essential for timely and appropriatetreatment which can limit the morbidity and prevent further complications

Calcifying fibrous tumour: a rare case report of an exceptional lesion localized in retroperitoneum, mesentery and pelvis

Calcifying fibrous tumours are rare benign lesions affecting mostly children and young adults. A 17-year-old female presented with abdominal pain and abdominal distention. Physical examination revealed intra-abdominal mass occupying retro peritoneum and right iliac fossa. Excisional biopsy from peritoneum and mesentery were performed. Histopathologically, it was composed of hypocellular hyalinised collagenized stroma, spindle cells, psammomatous and dystrophic calcification and mononuclear inflammatory cell infiltration. Authors are here in reporting a case of calcifying fibrous tumour and discussing its clinical and morphological features with regard to the literature.

Pattern distribution of abnormal hemoglobin variants by cation exchange High Performance Liquid Chromatography: a study of 9,116 subjects

Background: The present study was conducted to identify pattern distribution of abnormal haemoglobin variants by using HPLC method in a tertiary care hospital, Surat, Gujrat, India.Methods: A cross sectional study of one-year duration was conducted including 9,116 patients screened for the presence of abnormal haemoglobin variants. Blood samples were initially tested for solubility test and run on automated haemoglobin analyzer for complete haemogram. All the suspected and family study cases were processed for HPLC (Bio-Rad Variant II) for conclusive diagnosis. Patients with a history of recent blood transfusion of less than 3 months duration were excluded from the study.Results: A total of 9,116 cases (1390 males, 7726 females) were included in the present study. The age group of patients ranged from 1 month to 95 years. Solubility test and complete haemogram were performed in all the cases. Out of the 9,116 cases, 8409(92.24%)cases had normal HPLC pattern. 492(5.40%)cases were diagnosed as sickle cell trait, 176(1.93%) cases as sickle cell disease, 29(0.32%) cases as β thalassaemia trait, 1(0.01%) case as β thalassaemia major, 2(0.02%)cases as Hb E heterozygous and 03 (0.07%) cases as Hb D Punjab heterozygous. One case of double heterozygous for Hb E-β thalassaemia was also found.Conclusions: HPLC is a rapid, accurate and useful method for diagnosing haemoglobinopathies. It serves as an reliable tool in diagnosing the presence of abnormal haemoglobin variants in suspected cases on routine haematology in developing countries like India, where the resources for detection of haemoglobinopathies are limited. Early diagnosis may help in proper management of patients.

Blood lead levels in children with encephalopathy.

Objective: To determine the prevalence of elevated blood lead levels (EBLL i.e blood lead ³10µg/dL, Centers Disease Control criteria) in children with encephalopathy. Setting: Hospital. Design: Case control study. Participants: 100 children, 49 with encephalopathy and 51 consecutive hospital controls. Outcome measures: Blood lead levels, demographics, clinical, environmental correlates and residual neurological sequel or death at discharge. Results: 42 (encephalopathy) and 49 (hospital controls) children were available for analysis. The overall (n=91) mean blood lead was 7.88±10.44 µg/dL (range 0.07-67.68 µg/dL). The predictors of EBLL were presence of wasting (P<0.03), anemia (P<0.04), use of surma (P< 0.02), recent removal of house paint (P<0.01) or recently repainted (P<0.01). The mean blood lead levels were significantly higher (P<0.01) in patients of encephalopathy (12.18±13.90 µg/dL) than in controls (4.19±2.84 µg/dL). EBLL was present in 3/17 (17.6%) patients with infective encephalopathy and in 18/25 (72%) with non-infective encephalopathy. The proportion of children with residual neurological sequelae, or death increased when associated with EBLL (0 to 21%, and 69% to 100% respectively). Conclusion: Children hospitalized with encephalopathy have elevated blood lead levels.

Prognostic value of direct bilirubin in neonatal hyperbilirubinemia.

OBJECTIVE: To determine the prognostic value of indirect and direct hyperbilirubinemia in neonates with jaundice. METHODS: A cohort of 92 consecutive neonates reporting with hyperbilirubinemia to a tertiary care center were followed up till well and discharged, or, till death to assess risk and rate of mortality. RESULTS: The baseline median values of total, direct and indirect bilirubin in the cohort of 21.8, 1.6 and 18.6 mg/dl, respectively, were used as cut-offs for high and low levels. Using survival analyses i.e. Kaplan-Meier plots, logrank tests and multivariate Cox proportional hazards regression models to adjust for other strong predictors such as receipt of breastfeeding, being small for gestational age (SGA) and exchange transfusion, high direct bilirubin (> or = median value of 1.6 mg/dl) was independently associated with a higher and faster mortality. CONCLUSION: This study showed that direct bilirubin has independent and additive prognostic value and due attention should be given to newborns with raised levels.

Prices & availability of common medicines at six sites in India using a standard methodology.

BACKGROUND & OBJECTIVE: The price and availability of medicines are key components in determining access to effective treatment. Data on prices and availability of common medicines in public and private sector in different States of India are scarce. Hence, surveys were undertaken in different States of India to evaluate these metrics. METHODS: During October 2004 to January 2005, six surveys were undertaken simultaneously in five States of India to assess medicine prices and availability of essential medicines (n = 21-28) using the World Health Organization and Health Action International methodology. Surveys were conducted at Chennai, Haryana, Karnataka, West Bengal, and at two sites in Maharashtra. For each medicine, data were collected for the Innovator Brand (IB), Most Sold Generic (MSG), and Lowest Priced Generic (LPG) at randomly selected public and private facilities in each site surveyed. Prices were compared to an international reference benchmark (expressed as median price ratio - MPR). RESULTS: The procurement price of medicines in the public sector was 0.27 to 0.48 times the international reference price. However, these medicines were inadequately available and the median availability in the public sector ranged from 0 to 30 per cent. The median prices of medicines in the private sector were less than twice the IRP, although a few innovator brands were more expensive. No difference was observed between the prices of the most sold generic (MSG) and the lowest priced generic (LPG) available at the facilities. Interestingly, price variation was observed among different generic equivalents of ciprofloxacin in each region. The price of LPG diazepam in the private sector was thirty three times its procurement price in the public sector. INTERPRETATION & CONCLUSION: The survey revealed low procurement prices and poor availability in the public sector. Thus, the majority of the population purchased medicines from private pharmacies, where generics were usually available although prices of certain medicines were high. Various policy measures could increase the availability and accessibility of medicines for the population.

A tool for rapid socioeconomic assessment.

OBJECTIVE: To validate a simple wealth index scale (WIS) based assessment of socioeconomic status and compare it with existing kuppuswamy(KUP) scale. METHODS: Families of 300 children aged 6 to 59 months of acute diarrhoea enrolled in a cross-sectional study were interviewed for socio economic status using both 8 item ownership scale (WIS) and Kuppuswamy (KUP) scale, validated against a reference standard Income Scale (IS). RESULTS: Out of 111 people classified as low based on Income scale (IS), 17% were identified by WIS, and 21% by KUP. In the upper low, 69.4% were identified by WIS and 84.3 % by KUP. Amongst the low middle group the WIS identified 27.6% while KUP identified 10.6% and amongst upper middle patients 30% were identified by WIS and 15 % by KUP. There were none in the upper income of WIS or KUP category. The WIS performed well in all income categories whereas the KUP was better for upper low and low income categories. The agreement between WI and KUP was 55.56%. CONCLUSION: KUP scale is lengthy and difficult to administer by pediatric students and biased towards professional qualifications and education, rather than actual standard of living. It can be replaced by a simple 8 item ownership scale (WI) which is robust for all income groups and also shows good agreement with KUP.

Efficacy of breast milk gastric lavage in preterm neonates.

OBJECTIVE: To evaluate effects of gastric lavage with mother's milk starting 4 hours after birth, in hospitalized preterm newborns otherwise on exclusive parenteral fluids. METHOD: Study design: Randomized controlled trial. Sick preterm babies were assigned to receive in addition to parenteral fluids, either gastric lavage with mother's milk within 4 hours of birth and subsequently every 3 hours till tolerance of nutritive enteral feeds (intervention or BML group, n = 40), or remain nil per orally till tolerance of nutritive enteral feeds (control or NPO group, n = 40). The main outcome was the mean number of days of parenteral fluids till successful tolerance of nutritive enteral feeds. They were also evaluated for mean duration of hospital stay, development of new complications, and mortality. RESULT: Despite sicker babies in the BML group at baseline, the mean duration of exclusive parenteral fluid was significantly less (P = 0.003) in BML (3.9 +/- 1.5 days as compared to 5.4 +/- 2.6 days in NPO). In the NPO group 60% of the babies stayed longer than 3 weeks in hospital compared to only 30% in the BML group. The risk of development of new complication after randomization was also significantly less in BML group [RR 0.61 (95% CI 0.40-0.95) (P=0.03)]. Incidence of sepsis was 44% less in BML group [30% in BML, 55% in NPO group; RR 0.58; 95% CI 0.35-0.97; P = 0.02]. On multivariate logistic regression, BML group, birth weight and absence of complication at the time of hospitalization were strong predictors of improved outcome. There was no difference in mortality between 2 groups. CONCLUSION: This study showed that early exposure to even small amounts of mother's milk in sick preterm neonates significantly reduced the days on parenteral fluids, risk of sepsis and the duration of hospital stay without any adverse effect.

Quality of life in children with sickle cell hemoglobinopathy.

OBJECTIVE: To identify specific domains and traits that are most affected in patients with sickle cell anemia and traits with respect to normal children. METHODS: Children attending the regional hemoglobinopathy center at IGMC, Nagpur in age group of 8-14 years were assessed. Of 52 children studied, 25 had sickle cell anemia (SCA), 12 had sickle cell trait (SCT) and 15 wre normal control. The (quality of life (QOL) was assessed using multidimensional interview based questionnaire. RESULTS: All domains, physical, psychosocial, cognitive and morbidity were affected. In SCA playing and mobility were most affected. There was feeling of sadness or disinterest and lack of support from teachers. The school attendance, vocational achievement perception, entertainment and participation in cultural activities were also affected. The intensity of weakness and pain was greater in SCA children who left that they were affected by a major illness. The unusual finding was that the SCT children also showed affection of all domains as compared to normal children, which was perhaps due to the stigma of the disease. CONCLUSION: QOL is affected in children with sickle cell disease (SCD) and to a lesser extent in SCT. Interventions to improve QOL should target the affected items. Improving awareness of the disease and its manifestation will help to alleviate the psychosocial affliction of children with SCT.

Therapeutic evaluation of zinc and copper supplementation in acute diarrhea in children: double blind randomized trial.

OBJECTIVE: To test the hypothesis that daily supplementation of zinc and copper mixed with the oral rehydration solution (ORS) reduces the duration and the severity of acute diarrhea in children. METHODS: In a randomized, double blind, placebo controlled trial children aged 6 months to 59 months in an urban hospital with acute diarrhea, were assigned to receive the intervention of once daily 40 mg of zinc sulfate and 5 mg of copper sulfate dissolved in a liter of standard ORS (n = 102) or placebo (50 mg of standard ORS powder) dissolved in a liter of ORS (n = 98). RESULT: The baseline characteristics in the two groups were similar. The mean survival time (days) (SE) with diarrhea was not significantly different in the treatment (4.34 (0.2)) as compared to the placebo group (4.48 (0.2)), nor was there any difference in the median time to cure. Cure was less likely with longer duration of diarrhea prior to enrollment (P < 0.001), if the time taken for rehydration was more (P = 0.001) and if intravenous fluids were used (P = 0.03) regardless of the micronutrient supplementation. The proportion of children with diarrhea > 4 days was 46% in the placebo group with an adjusted odds ratio (OR) (95% CI) of 1.19 (1.58, 0.9; P = 0.2) as compared to 39% in the supplemented group. The most important risk factor for diarrhea > 4 days was diarrheal duration prior to enrollment with OR = 6.25 (3.7, 11.1). The supplemented group however had less severity of diarrhea with a lower proportion of children requiring unscheduled intravenous fluids (OR = 0.4; 95% CI 0.05, 2.2), with weight loss (OR = 0.7; 95% CI; 0.4, 1.3), with complications (OR = 0.15; 0.01, 1.3) and had no deaths as compared to two in the placebo group. CONCLUSIONS: This study showed that the most important predictor for duration of diarrhea in children was the severity of the disease at enrollment, and, not the supplementation. There were clinical beneficial effects of supplementation on rate of any complications and mortality. A larger trial is warranted before supplementation of micronutrients mixed with ORS are recommended for management of acute diarrhea.

Sickle cell disease in central India.

OBJECTIVE: The incidence and the risk factors of sickle cell disease (SCD), vaccinated with Pneumococcal vaccine and on penicillin prophylaxis has not been previously reported in India. METHODS: This prospective hospital based study followed 325 children on penicillin prophylaxis, of which 161 were vaccinated for pneumococci, over 146.84 person years to determine the incidence and determinants of crisis (SCC) and infections. The average age at presentation was 7.05 +/- 3.26 years with male preponderance below 2 years. RESULTS: The main causes for hospitalizations were for blood transfusion, SCC and infections. The incidence of SCC was 1.25 per patient per year and that of infection was 1.38 per person per year. The risk factors for SCC were Mahar caste (p = 0.007) non-compliance (p = 0.000) and protein energy malnutrition (PEM) (p = 0.0015) and for infection were also PEM (p = 0.023), Mahar caste (p = 0.021) and noncompliance (p = 0.001). CONCLUSION: Malnutrition and non-compliance with medication increased the patient's susceptibility to SCC and infections.