Chimeric monoclonal antibody to tumor necrosis factor alpha (infliximab) in psoriasis.

BACKGROUND: Insights into the pathogenesis of psoriasis have provided opportunities to target key steps in the disease process. Tumor necrosis factor-alpha (TNF- alpha) being crucial to the pathogenesis of psoriasis, monoclonal antibodies against this cytokine have proved useful in its treatment. AIM: To study the efficacy of chimeric monoclonal antibody to TNF- alpha (infliximab) in Indian patients with recalcitrant psoriasis vulgaris. MATERIALS AND METHODS: Three patients with recalcitrant psoriasis vulgaris were studied. Baseline haemogram, biochemical parameters, chest radiograph and Mantoux skin test were performed. A loading dose regimen of 5 mg/kg infliximab was administered at weeks 0, 2 and 6. PASI assessment, adverse drug event monitoring and laboratory assessments were carried out at 2-week intervals until week 10. Patients were followed up until week 22 for relapse. RESULTS: Infliximab was well tolerated. The mean PASI was 25.4 at presentation and declined to 5.5 at 10 weeks. PASI 75 was attained at a mean of 9.6 weeks. Relapse occurred at a mean of 18.6 weeks after the first infusion. CONCLUSIONS: This study on Indian patients brings out the importance of cytokine-based therapies in psoriasis. Indigenous production could make these therapies a viable therapeutic option for psoriasis patients in the near future.

Medical problems in surgical patients.

OBJECTIVES: There has been an increase in surgical cases due to physical violence, accidents and weapon related injuries. This study was undertaken to assess the medical problems in general surgical cases and due to various injuries. METHODS: All general surgical cases and casualties arising out of weapon related, accidents and blunt injuries admitted to a zonal hospital over a period of one and half years were studied. Only cases who developed a medical illness due to surgical cause, anaesthetic or surgery were included. Evaluation and treatment was done alongwith the surgeon till discharge/death. Details were analysed to ascertain the type of surgical illness, medical complication and the outcome of treatment. RESULTS: There were seven hundred sixty two (53.8%) general surgery cases and six hundred fifty four (46.2%) cases due to various injuries. After excluding cases with prior known medical illness, thirty seven patients were studied. There were eight (1.05%) patients out of seven hundred sixty two general surgery cases and twenty nine (4.43%) out of six hundred fifty four injury cases. Weapon related injury cases were the maximum. Their medical problems related to the organ injury, fat embolism and sepsis. Soft tissue injury was next common, they all developed renal failure. Vehicle accident victim(3) were few and developed fat embolism, aspiration. Two patients out of thirty seven succumbed to post anaesthetic complications. CONCLUSION: The incidence of medical problem in injury related cases are more than in general surgery cases. The type of injury contributes to the medical problem. Increase in mortality and morbidity is because of emergency nature of surgery. This problem needs special study.

BACTERIOPHAGE PATTERN AND METHICILLIN RESISTANCE OF STAPHYLOCOCCUS AUREUS ISOLATED FROM HOSPITALISED PATIENTS.

Ninety two strains of Staphylococcus aureus isolated from hospitalized patients were phage grouped and phage typed and their resistance pattern to methicillin were studied. Forty five (48.9%) strains were nontypable, followed by mixed group in 23 (25%). The phage groups I, II, III, V and miscellaneous groups were 3.3 per cent, 7.6 per cent, 8.7 per cent, 1 per cent and 3.3 per cent respectively. Majority of the strains were methicillin resistant. Out of 45 nontypable strains 33 (73.3%) were methicillin resistant whereas in mixed phage group methicillin resistance was found in 52 per cent. The inadequacy of available phages for typing, rising incidence of methicillin resistance in untypable strains and variance of phage group and phage types at various places has been highlighted.

Detection and prevention of childhood disability with the help of Anganwadi workers.

OBJECTIVES: To evaluate the role of Anganwadi Workers (AWW) for detection and prevention of disability in children below 6 years of age. DESIGN: Cross sectional and longitudinal follow up. SETTING: Ten Anganwadi Centers in ICDS Urban Project. METHODS: Trained AWWs identified disabilities and instituted preventive measures like immunization and supplementary nutrition. Simultaneous independent verification by pediatricians. Repeat survey after 6 mo of follow-up. RESULTS: Amongst the 1545 children, AWW identified disability in 126 subjects which were verified in 118 cases by pediatricians. The disability rate was 7638 per 100,000 population. Visual, mental, orthopedic, speech and hearing disabilities rates were 4790, 2654, 583, 518 and 453 per 100,000 population, respectively. In the repeat survey, 35 of the 74 children with visual disability (mostly xerophthalmia), 4 of the 9 with orthopedic disability and 3 of the 7 with hearing disability could be managed satisfactorily. CONCLUSIONS: AWW can help in early detection and appropriate management of incipient and preventable childhood disabilities.

PIP: This study was conducted in the Integrated Child Development Services (ICDS) urban project of Gorakhpur in 10 randomly selected Anganwadi centers from October 1984 to September 1985. Anganwadi workers (AWW) were given in-service orientation and training to detect various types of disabilities in children below 6 years, 4 hours per day for 6 days at BRD Medical College. The study evaluated the role of AWWs in detecting and preventing disability in children younger than age 6 years. The trained AWWs identified disabilities and instituted preventive measures such as immunization and supplementary nutrition, together with the simultaneous independent verification by pediatricians, and a repeat survey after 6 months of follow-up. Among the 1545 children, the AWWs identified disability in 126 subjects which were verified in 118 cases by pediatricians. The disability rate was 7638 per 100,000 population. Visual, mental, orthopedic, speech, and hearing disabilities rates were 4790, 2654, 583, 518, and 453 per 100,000 population, respectively. In the repeat survey, 35 of the 74 children with visual disability (mainly xerophthalmia), 4 of the 9 with orthopedic disability, and 3 of the 7 with hearing disability could be managed satisfactorily. It is concluded that AWWs can help in the early detection and appropriate management of incipient and preventable childhood disabilities.

Surveillance of drug induced diseases in children.

A hospital based prospective study on drug induced diseases (DID) in children below 14 years of age was done for a duration of two years. A total number of 20,310 patients were examined in pediatric department during this period, out of which 204 (1.004%) patients were diagnosed as DID. Children with severe reactions were admitted in pediatric ward for in hospital intensive surveillance. The male:female ratio in DID was 1.2:1. DID were most common in neonates (24.51%). Erythmatous maculopapular rashes (67.12%) formed the most common pool of DID in neonates. Thrombophlebitis (41.56%) was most commonly seen in infants above 28 days of life, and in children up to 14 years of age. Out of 204 cases of DID, 9 (4.41%) died. Aplastic anemia was most morbid DID, as all the 7 patients of aplastic anemia died. Chloramphenicol was responsible for all the cases of aplastic anemia. Other two deaths were from erythma multiforme and C.C.F. The most commonly involved drugs, other substances and vaccines were baby powders, massage oils, ampicillin, co-trimoxazole, i.v. infusions (electrolytes and mannitol), DPT and measles vaccines.

Growth patterns in breastfed babies during first six months of life.

Growth of exclusively breastfed 126 normal newborns in urban slums and those delivered at Nehru Hospital, Medical College, Gorakhpur were studied upto six months of age. The average weight of both boys and girls was almost equivalent to the 25th percentile of NCHS standard upto 3 months but fell below these standards thereafter. The average length in both boys and girls was between 25th and 50th percentile of NCHS data. The average head circumference in girls was between 25th and 50th percentile of NCHS data at all ages but in boys it was between 10th and 25th percentile at 4, 5 and 6 months of age. The average weight, length, head and chest circumference in both boys and girls were comparable to ICMR standards. The observations indicate that exclusive breastfeeding should be promoted for adequate growth of infants during first six months of life.

PIP: The study examined the growth patterns of breast-fed newborns from two populations of Gorakhpur, India, during January-December 1985: an urban slum population and others delivered at the B.R.D. Medical College. The sample included 52 community-delivered infants and 74 hospital-delivered infants weighing more than 2.5 kg at birth and without any congenital abnormalities or illness. Breast feeding was initiated by the newborns from the slum area after 2-3 days, while hospital-delivered infants were nursed immediately after delivery. Anthropometric measurements were taken within 24 hours of a hospital delivery and within a week after birth in slum community areas. Thereafter measurements were taken monthly for 6 months, and mothers were reinforced to continue breast feeding. Findings included only 76 infants were followed up for the entire 6 month period: 100% of the 52 community infants (31 boys and 21 girls) and only 32.4% (15 boys and 9 girls) of the hospital-delivered infants. The mean weight of infants was lower than the 50th percentile of the US National Center for Health Statistics (NCHS) data. Compared to the ICMR standard, weight differences for girls were significant only at 0 and 6 months of age, while for boys all differences between standards were significant. The mean weight of most infants was above the under-nutrition curve on the ICMR growth charts. Height was between the 25th and 50th percentile of the NCHS data. The ICMR values were comparable. The average head circumference was in the same percentiles as height for all female ages, but for boys at 4, 5, and 6 months the ranking was in the 10th to 25th percentile. Values were comparable to ICMR values. The gain in head circumference was comparable in 9 male and 13 female infants. Chest circumference was comparable to the only available ICMR values. The head/chest ratios showed normal growth of Indian children. The results confirmed the health advantages for growth in breast fed Indian children.

Pregnancies in adolescents: fetal, neonatal and maternal outcome.

We studied the perinatal morbidity and mortality among adolescent pregnancies in the semi-urban population of Gorakhpur. The number of eligible couples (females 15-44 yrs) were 24,000. Out of 430 adolescent married girls, 242 (56.3%) became pregnant during the study period. Nineteen (7.8%) of adolescent pregnancies were in the maternal age group less than 15 years and 110 (45.5%) and 113 (46.7%) pregnancies were in the age group 15-17 yrs and 17-19 yrs, respectively. The incidence of low birth weight babies was 67.3% of all live births. Infections during neonatal period, congenital anomalies and birth injuries were seen in 21.6, 8.6 and 13.1% newborns, respectively. Neonatal mortality rate was 136.2/1000 live births. Three adolescent mothers died during pregnancy or puerperium due to causes related to pregnancy. The incidence of LBW, neonatal and maternal morbidity and mortality associated with adolescent pregnancies were significantly higher.

JE virus encephalitis: 1988 epidemic at Gorakhpur.

Gorakhpur region experienced the most serious outbreak of Japanese encephalitis (JE) in 1988 in which 875 children were admitted in the Department of Pediatrics, BRD Medical College, Gorakhpur. Children between 7-10 years age group constituted half (49.3%) of these cases, convulsions (83.8%), altered sensorium (78.2%), headache (68.8%) and hypertonia (77.0%) were the main presenting features. IgM against JE virus was demonstrated in 18/25 CSF and 27/53 sera collected from these children. Significant titres of HI antibodies against JE were present in 498/670 patients. Patients were managed symptomatically. Dexamethasone and dopamine were given to only 137 (15.7%) children admitted with shock and peripheral circulatory failure. Almost a third (31.8%) of the patients expired, 51.4% recovered completely and 10.7% recovered partially. Corticosteroids did not improve the outcome. Twenty four patients had recurrence of symptoms after excellent recovery from acute attack of whom two died and 5 developed neurological deficits.

Prevalence and abuse of psychoactive substances in children and adolescents.

The present study has been carried out in the slum areas of Gorakhpur city, covering a population of 10,187 in the four colleges of Gorakhpur. Five hundred and eighty children and adolescents in urban slums, and 750 college students between 10-18 years were studied by means of a questionnaire card for detection of prevalence rate and various others co-relates of abuse of psychoactive substances. Overall, prevalence of abuse of psychoactive substances was 25% in slum areas, and 18% in college students. Abuse of tobacco was most frequent (50.3% & 72.5%) followed by that of alcohol (11.7% & 16.2%) in both the groups respectively. Cannabis was also used by some children (0.6%). More abusers were from Hindu families with low educational status and low family income. Surprisingly no one was found to be abusing tablets and street drugs.

Neonatal morbidity and mortality in ICDS urban slums.

PIP: A communitywide prospective survey was conducted in the urban slums of Gorakhpur, to elicit information on factors contributing to India's high rate of neonatal mortality. Neonatal mortality accounts for more than 50% of total infant mortality in India. To successfully reduce infant mortality to 60/1000 live births, more information is needed on the contribution of prematurity, low birth weight, infections, respiratory distress, birth asphyxia, hyperbilirubinemia, birth injury, congenital malformation, and other determinant factors of neonatal morbidity and mortality, especially in urban slums. Compared with the standards of more developed countries, high levels of neonatal morbidity and mortality were found with the main causes being infections and respiratory distress. Neonatal mortality was found to bear an inverse relationship with birth weight and gestational age. Higher mortality rates were observed in institutional deliveries, despite the fact that the overall majority of mortality occurred in the home. Neonatal mortality was found to be significantly higher (p.001) in home deliveries conducted by untrained dais. Proper training of traditional dais and paramedical workers would minimize the extent of these deaths.^ieng

Prescription audit of under six children living in periurban areas.

One hundred and seventy two children were prescribed, in 212 episodes of illness, antimicrobial agents (28.4%), followed by antidiarrheals (10.9%), nutritional products (9.4%), analgesics (7.5%) and steroids (6.8%). Ampicillin (22.7%) and cotrimoxazole (12.7%) were the most commonly prescribed antimicrobials. Tetracyclines, which are not indicated in children below 8 years, were used in 7.1% of total exposures of chemotherapeutic agents. Penicillin, a comparatively safe and useful drug, was used only in 4.5% exposures. Analgin and hydroxyquinolines were used frequently. Corticosteroids were used for simple ailments like diarrhea, fever and jaundice. ORS was used in only 13.9% episodes of diarrhea. Adverse drug reactions were noted in 30 (17.4%) cases and death in 6 (3.5%) cases. The average cost per prescription for neonates was Rs 32.43 and for a child was Rs 30.65. Weight of the children was not taken prior to prescribing drugs. There is need for prescription audit as there is high consumption rate of drugs, with overuse of antimicrobial and nutritional products, and misuse of steroids.

Mortality patterns in low birth weight babies in ICDS urban slum area.

There were 920 live-births over the period of one year in urban slums (covering 40 anganwadi centres) of Gorakhpur city. Incidence of low birth weight (LBW) babies weighing 2.5 kg or less and those weighing 2 kg or less were 40.7% (19.8% preterm LBW and 80.2% term LBW) and 24% (25.3% preterm LBW and 74.7% term LBW) respectively. Incidence of preterm babies was 8.5%. Infections and respiratory distress were found to be the major killers of LBW babies. The neonatal mortality rate was observed to be significantly high in LBW and preterm babies. Again, babies weighing 2 kg or less and preterm were at greater risk and should be referred to specialised neonatal centres while those weighing 2.001-2.5 kg could be looked after at home by trained personnel in domiciliary newborn care.