Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India.

BACKGROUND: Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden. METHODS AND FINDINGS: We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population. CONCLUSIONS: The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Evaluation of terrestrial plants extracts for uranium sorption and characterization of potent phytoconstituents.

Sorption capacity of four plants (Funaria hygrometrica, Musa acuminata, Brassica juncea and Helianthus annuus) extracts/fractions for uranium, a radionuclide was investigated by EDXRF and tracer studies. The maximum sorption capacity, i.e., 100% (complete sorption) was observed in case of Musa acuminata extract and fractions. Carbohydrate, proteins, phenolics and flavonoids contents in the active fraction (having maximum sorption capacity) were also determined. Further purification of the most active fraction provided three pure molecules, mannitol, sorbitol and oxo-linked potassium oxalate. The characterization of isolated molecules was achieved by using FTIR, NMR, GC-MS, MS-MS, and by single crystal-XRD analysis. Of three molecules, oxo-linked potassium oxalate was observed to have 100% sorption activity. Possible binding mechanism of active molecule with the uranyl cation has been purposed.

Diagnosis and Management of Global Development Delay: Consensus Guidelines of Growth, Development and Behavioral Pediatrics Chapter, Neurology Chapter and Neurodevelopment Pediatrics Chapter of the Indian Academy of Pediatrics.

JUSTIFICATION: Global developmental delay (GDD) is a relatively common neurodevelopmental disorder; however, paucity of published literature and absence of uniform guidelines increases the complexity of clinical management of this condition. Hence, there is a need of practical guidelines for the pediatrician on the diagnosis and management of GDD, summarizing the available evidence, and filling in the gaps in existing knowledge and practices. PROCESS: Seven subcommittees of subject experts comprising of writing and expert group from among members of Indian Academy of Pediatrics (IAP) and its chapters of Neurology, Neurodevelopment Pediatrics and Growth Development and Behavioral Pediatrics were constituted, who reviewed literature, developed key questions and prepared the first draft on guidelines after multiple rounds of discussion. The guidelines were then discussed by the whole group in an online meeting. The points of contention were discussed and a general consensus was arrived at, after which final guidelines were drafted by the writing group and approved by all contributors. The guidelines were then approved by the Executive Board of IAP. Guidelines: GDD is defined as significant delay (at least 2 standard deviations below the mean with standardized developmental tests) in at least two developmental domains in children under 5 years of age; however, children whose delay can be explained primarily by motor issues or severe uncorrected visual/hearing impairment are excluded. Severity of GDD can be classified as mild, moderate, severe and profound on adaptive functioning. For all children, in addition to routine surveillance, developmental screening using standardized tools should be done at 9-12 months,18-24 months, and at school entry; whereas, for high risk infants, it should be done 6-monthly till 24 months and yearly till 5 years of age; in addition to once at school entry. All children, especially those diagnosed with GDD, should be screened for ASD at 18-24 months, and if screen negative, again at 3 years of age. It is recommended that investigations should always follow a careful history and examination to plan targeted testing and, vision and hearing screening should be done in all cases prior to standardized tests of development. Neuro-imaging, preferably magnetic resonance imaging of the brain, should be obtained when specific clinical indicators are present. Biochemical and metabolic investigations should be targeted towards identifying treatable conditions and genetic tests are recommended in presence of clinical suspicion of a genetic syndrome and/or in the absence of a clear etiology. Multidisciplinary intervention should be initiated soon after the delay is recognized even before a formal diagnosis is made, and early intervention for high risk infants should start in the nursery with developmentally supportive care. Detailed structured counselling of family regarding the diagnosis, etiology, comorbidities, investigations, management, prognosis and follow-up is recommended. Regular targeted follow-up should be done, preferably in consultation with a team of experts led by a developmental pediatrician/ pediatric neurologist.

Efficacy of Preprocedural Boric Acid Mouthrinse in Reducing Viable Bacteria in Dental Aerosols Produced during Ultrasonic Scaling.

INTRODUCTION: Aerosols and droplets contaminated with bacteria and blood are produced during ultrasonic scaling. Measures to control aerosol contamination in dental clinics are recommended by the Centers for Disease Control and Prevention. This study aimed to evaluate the efficacy of preprocedural boric acid (BA) mouthrinse in reducing bacterial contamination in dental aerosols generated during ultrasonic scaling. MATERIALS AND METHODS: This was a randomised clinical trial in 90 systemically healthy subjects (25-55 yrs) diagnosed with chronic periodontitis who were allocated into three groups of 30 subjects each to receive, Group A - 0.12% chlorhexidine (CHX), Group B - 0.75% BA and Group C-water, as a preprocedural rinse for 1 min. The aerosol generated while performing ultrasonic scaling for 30 min was collected at three locations on blood agar plates. Incubation of the blood agar plates at 37°C for next 48 h for aerobic culture was performed and subsequently colony-forming units (CFUs) were counted. RESULTS: CFUs in Group A were significantly reduced compared with Group B (P < 0.001). When we compare CFUs in all the three groups, CFUs in Groups A and B were statistically significantly reduced compared with Group C (P < 0.001). Furthermore, it was also observed that the assistant's chest area had lowest CFUs whereas patient's chest area had highest. CONCLUSION: This study recommends routine use of preprocedural mouthrinse as a measure to reduce bacterial aerosols generated during ultrasonic scaling and that 0.12% CHX gluconate is more effective than 0.75% BA mouthwash in reducing CFUs count.

Multicenter, hospital-based surveillance of rotavirus disease and strains among indian children aged <5 years.

BACKGROUND: Current, nationally representative data on rotavirus disease burden and rotavirus strains in India are needed to understand the potential health benefits of rotavirus vaccination. METHODS: The Indian Rotavirus Strain Surveillance Network was established with 4 laboratories and 10 hospitals in 7 different regions of India. At each hospital, children aged <5 years who presented with acute gastroenteritis and required hospitalization with rehydration for at least 6 h were enrolled. A fecal specimen was obtained and was tested for rotavirus with use of a commercial enzyme immunoassay, and strains were characterized using reverse-transcription polymerase chain reaction. RESULTS: From December 2005 through November 2007, rotavirus was found in approximately 39% of 4243 enrolled patients. Rotavirus was markedly seasonal in northern temperate locations but was less seasonal in southern locations with a tropical climate. Rotavirus detection rates were greatest among children aged 6-23 months, and 13.3% of rotavirus infections involved children aged <6 months. The most common types of strains were G2P[4] (25.7% of strains), G1P[8] (22.1%), and G9P[8] (8.5%); G12 strains were seen in combination with types P[4], P[6], and P[8] and together comprised 6.5% of strains. CONCLUSIONS: These data highlight the need for development and implementation of effective prophylactic measures, such as vaccines, to prevent the large burden of rotavirus disease among Indian children.

Health-related quality of life of children with newly diagnosed specific learning disability.

The objective of this study was to measure health-related quality of life (HRQL) of children with newly diagnosed specific learning disability (SpLD) using the Child Health Questionnaire-Parent Form 50. We detected clinically significant deficits (effect size > or = -0.5) in 9 out of 12 domains: limitations in family activities, emotional impact on parents, social limitations as a result of emotional-behavioral problems, time impact on parents, general behavior, physical functioning, social limitations as a result of physical health, general health perceptions and mental health; and in both summary scores (psychosocial > physical). Multivariate analysis revealed having > or = 1 non-academic problem(s) (p < 0.0001), attention-deficit hyperactivity disorder (p = 0.005) or first-born status (p = 0.009) predicted a poor psychosocial summary score; and having > or =1 non-academic problem(s) (p = 0.006) or first-born status (p = 0.035) predicted a poor physical summary score. HRQL is significantly compromised in children having newly diagnosed SpLD.

Protecting Indian schoolchildren against rabies: pre-exposure vaccination with purified chick embryo cell vaccine (PCECV) or purified verocell rabies vaccine (PVRV).

Although rabies can be effectively prevented by means of preexposure or post-exposure prophylaxis, in India, an estimated 17,000 to 20,000 human rabies deaths occur annually. Tragically, 50% of these victims are children under the age of 15. In addition to immediate post-exposure prophylaxis measures, including active and passive immunization, pre-exposure vaccination using tissue culture vaccines is a safe and effective but highly underutilized method of preventing rabies in humans living or working in areas at risk. This study assessed the safety and immunogenicity of Purified Chick Embryo Cell Vaccine (PCECV) and Purified Verocell Rabies Vaccine (PVRV), administered as a three-dose intramuscular pre-exposure regimen on days 0, 7 and 28 in 175 healthy schoolchildren. PCECV was administered after reconstitution using either 1.0 mL or 0.5 mL (half the diluent volume) and PVRV was given after reconstitution with 0.5 mL. Vaccine safety was assessed observer-blind, including pain assessment with a validated visual analogue scale for children. Rabies virus neutralizing antibody (RVNA) concentrations were measured on day 49 by RFFIT. All children developed adequate RVNA concentrations above 0.5 IU/mL. Solicited local and systemic reactions were within the range expected, pain after vaccination was reported in 2 to 12% of study subjects, fever was reported in 2 to 5%. There was no statistical difference by vaccination group or vaccination day. No unexpected or serious adverse event was reported during the study. In conclusion, PCECV and PVRV are safe and immunogenic when administered intramuscularly for pre-exposure prophylaxis of rabies in children. A 1.0 mL dilution volume for PCECV was as well tolerated as PVRV or PCECV reconstituted in half the volume.

Effectiveness of 3-day amoxycillin vs. 5-day co-trimoxazole in the treatment of non-severe pneumonia in children aged 2-59 months of age: a multi-centric open labeled trial.

This cluster randomized, open labeled trial was conducted to compare the effectiveness of 3 days of oral amoxycillin and 5 days of co-trimoxazole treatment in terms of clinical failure in children with World Health Organization (WHO) defined non-severe pneumonia in primary health centers in rural India. Participants were children aged 2-59 months with WHO defined non-severe pneumonia, with or without wheeze, who were accessible to follow up. From seven primary health centers in each arm, 2009 cases were randomized, 993 and 1016 in treatment with amoxycillin and co-trimoxazole, respectively. Fever was present in 1247 (62.1%) and wheeze in 443 (22.1%). There was good adherence and low loss to follow-up. Clinical failure on amoxycillin and co-trimoxazole on intention to treat analysis was 137 and 97, respectively (absolute difference = 0.04, 95% confidence interval: - 0.035-0.12). We conclude that there was no difference in effectiveness of oral co-trimoxazole or amoxycillin in treating non-severe pneumonia.

Fanconi-Bickel syndrome.

We present here the first case of Fanconi-Bickel syndrome, a rare type of glycogen storage disease, from India. A 17-month-old female child presented with severe growth retardation and abdominal distention. Clinical examination revealed a "doll-like" face, massive hepatomegaly, and rickets. Laboratory investigations confirmed severe hypophosphatemic rickets and proximal renal tubular dysfunction. Liver biopsy showed glycogen accumulation in the hepatocytes.

Impact of an education program on parental knowledge of specific learning disability.

BACKGROUND: A supportive home environment is one of the factors that can favorably determine the outcome of specific learning disability (SpLD) in a school-going child. However, there is no reliable information available on parental knowledge about SpLD. AIMS: To investigate parental knowledge of SpLD and to evaluate the impact of an educational intervention on it. SETTINGS AND DESIGN: Prospective questionnaire-based study conducted in our clinic. MATERIALS AND METHODS: From April to November 2002, 50 parents who were conversant in English and willing to follow up were interviewed. After the interview, each parent was administered a structured educational program and re-interviewed after 3 months. STATISTICAL ANALYSIS: The pre- and post-intervention responses were compared using Chi-square test. RESULTS: After the intervention, there was significant improvement in parental knowledge of (i) the meaning of the term 'SpLD' (32/50 vs. 50/50, P CONCLUSION: Parental knowledge of their child's SpLD is inadequate and this can be significantly improved by a single-session educational program.

Clinical and psychoeducational profile of children with specific learning disability and co-occurring attention-deficit hyperactivity disorder.

BACKGROUND: Almost 10% of school-going children have specific learning disability (SpLD) in the form of dyslexia, dysgraphia and/or dyscalculia. Attention-deficit hyperactivity disorder (ADHD) occurs as a comorbidity in about 20% of these children. AIMS: To document the clinical profile and academic history of children with SpLD and co-occurring ADHD. SETTINGS AND DESIGN: Prospective observational study conducted in our clinic. MATERIALS AND METHODS: From August to November 2004, 50 consecutively diagnosed children (34 boys, 16 girls) were included in the study. SpLD was diagnosed on the basis of psychoeducational testing. Diagnosis of ADHD was made by DSM-IV-revised criteria. Detailed clinical and academic history and physical and neurological examination findings were noted. STATISTICAL ANALYSIS: Chi-square test or unpaired student's t-test was applied wherever applicable. RESULTS: The mean age of children was 11.4 years (+/-SD 2.5, range 7-17.1). Fifteen (30%) children had a significant perinatal history, 12 (24%) had delayed walking, 11 (22%) had delayed talking, 5 (10%) had microcephaly, 27 (54%) displayed soft neurological signs and 10 (20%) had primary nocturnal enuresis. There were no differentiating features between the two gender groups. Their academic problems were difficulties in writing (96%), inattentiveness (96%), difficulties in mathematics (74%), hyperactivity (68%) and difficulties in reading (60%). All children had poor school performance, 15 (30%) had already experienced class retention and 20 (40%) had developed aggressive or withdrawn behavior. CONCLUSION: Children with SpLD and co-occurring ADHD need to be identified at an early age to prevent poor school performance and behavioral problems.

A Cross-Sectional Pharmacoepidemiological Study of the Utilization Pattern of Pre-Anesthetic Medications in Major Surgical Procedures in a Tertiary Care Hospital.

OBJECTIVE: A study of the utilization pattern of pre-anesthetic medications in major surgical procedures. MATERIAL AND METHODS: A cross-sectional, pharmacoepidemiological study was conducted among patients undergoing surgical procedures in routine or emergency conditions under general anesthesia. The utilization of pre-anesthetic medicines in all patients was reported. RESULTS: A total of 110 patients (mean age - 42.36 years; 57.27% males) were enrolled. The major (>10%) indications for surgery were carcinoma/tumor - 25 (22.73%), perforation peritonitis - 20 (18.18%), and intestinal obstruction - 11 (10%). All patients received ranitidine plus metoclopramide. Injections of ondansetron, midazolam, pentazocin, anticholinergic agents, and fentanyl were used in 103 (93.64%), 103 (93.64%), 92 (83.64%), 84 (76.36%), and 23 (20.91%) patients, respectively. The dosage of ondansetron was 4 mg in 95 patients (86.36%), while 89.09% patients received 1 mg of midazolam. In 86 patients (78.18%), pentazocine was used in a 15 mg dose. Among the anticholinergic agents, glycopyrrolate was used in 76 patients (69.09%). Glycopyrrolate was used in a 0.2 mg dose in 74 patients (97.37%). The major indications for the use of fentanyl were carcinoma - 8 (34.8%), perforation peritonitis - 4 (17.4%), and surgery for intestinal obstruction - 3 (13%). CONCLUSION: The administration of ondansetron, midazolam, and pentazocin is very common (>80% patients) as pre-anesthetic medication. Glycopyrrolate was the preferred anticholinergic agent. In cancer patients, the use of fentanyl is common.

Evaluation of dietary supplementation of omega-3 polyunsaturated fatty acids as an adjunct to scaling and root planing on salivary interleukin-1ß levels in patients with chronic periodontitis: A clinico-immunological study.

CONTEXT: Host modulation with omega-3 polyunsaturated fatty acids (ω-3 PUFAs) has anti-inflammatory and pro-resolution actions through replacing and inhibiting metabolism of arachidonic acid (AA). AIM: This study was aimed at evaluating clinical parameters and salivary levels of interleukin-1 beta (IL-1ß) after scaling and root planing (SRP) in chronic periodontitis patients, with and without dietary supplementation of ω-3 PUFAs. SETTINGS AND DESIGN: Forty otherwise healthy participants with severe chronic periodontitis were included. Full-mouth periodontal examination and scaling and root planing were done for test and control group (20 participants each). MATERIALS AND METHODS: The control group received SRP alone while test group received daily dose of 700 mg ω-3 PUFA capsules for 3 months. All clinical parameters were checked at baseline, 1 month, and 3 months' duration, whereas levels of IL-1ß were checked in saliva at baseline and 3 months after therapy. STATISTICAL ANALYSIS USED: T-test and repeated measure analysis of variance were used with Statistical Package for the Social Science Windows software. RESULTS: Improvements in all clinical outcomes were similar in both groups over 3 months. Improvements in clinical parameters were not statistically significant on intergroup comparison, except for improvement in Bleeding Index and reduction in levels of IL-1ß, which were statistically significant in test group as compared to control group (P < 0.05). CONCLUSION: Even though adjunct therapy with ω-3 PUFAs can modulate cytokine levels and show proresolution properties, its importance on clinical outcomes may be controversial. Thus, this may be used as an adjunctive management of chronic periodontitis.

The atmospheric electrical index for ENSO modoki: Is ENSO modoki one of the factors responsible for the warming trend slowdown?

Like the southern oscillation index (SOI) based on the pressure difference between Tahiti (17.5°S, 150°W) and Darwin (12.5°S, 130°E), we propose the new atmospheric electrical index (AEI) taking the difference in the model calculated atmospheric electrical columnar resistance (Rc) which involves planetary boundary layer height (PBLH) and aerosol concentration derived from the satellite measurements. This is the first non-oceanic index capable of differentiating between the conventional and modoki La Niña and El Niño both and may be useful in the future air-sea coupling studies and as a complementary to the oceanic indices. As the PBLH variation over Darwin is within 10% of its long term mean, a strong rise in the Rc over Darwin during the modoki period supports modoki's connection with aerosol loading. Our correlation results show that the intensity of El Niño (La Niña) event is almost independent (not independent) of its duration and the possibility of ENSO modoki being one of the factors responsible for the warming trend slowdown (WTS).

Recollections of Indian children after discharge from an intensive care unit.

OBJECTIVE: To analyze the recollections of children following discharge from the pediatric intensive care unit (PICU). DESIGN: Prospective interview-based study. SETTING: Multidisciplinary 111-bed general pediatric wards in a tertiary care hospital situated in Mumbai, India. PATIENTS: Fifty children aged between five and 12 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Children's responses to a semistructured interview were documented between the first and fifth day after their transfer and interpreted by content analysis. Thirty-seven children (74%) had neutral recollections, nine (18%) had negative recollections, and eight (16%) had positive recollections of their PICU stay. Twenty-six children (52%) stated clean environment and 18 (36%) stated doctors as good features, whereas 25 (50%) stated injections as bad features of the PICU. Thirty-two children (64%) remembered feeling scared, 37 (74%) being in pain, seven (14%) being thirsty, eight (16%) being hungry, and nine (18%) having disturbed sleep. Thirteen children (26%) appreciated the nurses and 33 (66%) the doctors for a good deed done by them. Fourteen children (28%) wanted changes to make the PICU stay comfortable. CONCLUSIONS: More toys, proactive measures to prevent intravenous catheter phlebitis, sedation to provide amnesia and good sleep, and adequate analgesia for various painful procedures are necessary for children in the PICU. Doctors and nurses should introduce themselves to patients and ensure that children are comfortable in bed and do not witness procedures being done on other children or a dead body.

Prognostic clinical variables in childhood tuberculous meningitis: an experience from Mumbai, India.

BACKGROUND: In India, tuberculous meningitis (TBM) is still a major cause of neurological disabilities and death. AIM: To identify the clinical variables which predict the outcome in childhood TBM. SETTING: Tertiary teaching hospital. DESIGN: Prospective observational study. MATERIALS AND METHODS: Thirty-six clinical variables were analyzed in 123 consecutive children with TBM admitted between May 2000 and August 2003. The outcome was assessed in terms of survival or death. Survival meant that the patient was discharged from hospital having made a complete recovery, or with disability. RESULTS: Twenty-five (20%) children recovered completely, 70 (57%) survived with disability, and 28 (23%) died. Employing univariate analysis nine variables correlated with survival with disability outcome: presence of tonic motor posturing, cranial nerve palsy, focal neurological deficit, hypertonia, moderate to severe hydrocephalus, cerebral infarction on cranial CT, and requiring shunt surgery, and absence of extracranial tuberculosis and no antituberculous-related hepatotoxicity; two variables correlated with fatal outcome: presence of deep coma (Glasgow coma scale score P = 0.012, d.f. = 1, OR 0.12, 95% CI 0.02-0.62) correlated with survival with disability outcome, and presence of deep coma (P = 0.030, d.f. = 1, OR 0.35, 95% CI 0.14-0.90) with fatal outcome. CONCLUSION: In children with TBM, the presence of hypertonia at admission is an independent predictor of neurological sequelae in survivors, and deep coma is an independent predictor of mortality.

Attention deficit hyperactivity disorder.

Attention Deficit Hyperactivity Disorder (ADHD) is a common behavioral disorder in children. It is characterized by motor hyperactivity, impulsivity and inattention inappropriate for the age. Approximately 5-10 % of school age children are diagnosed to have ADHD. The affected children show significant impairment in social behavior and academic performance. The DSM-5 criteria are useful in diagnosing three subtypes of ADHD based on presence of symptoms described in 3 domains viz ., inattention, hyperactivity and impulsivity. Co-morbidities like specific learning disability, anxiety disorder, oppositional defiant disorder are commonly associated with ADHD.Education of parents and teachers, behavioral therapy and medication are main components of management. Methylphenidate and Atomoxetine are effective in controlling symptoms of ADHD in most children. Research studies estimated that 30-60 % of children continue to show symptoms of ADHD in adulthood. The general practitioner can play an important role in early diagnosis, appropriate assessment and guiding parents for management of children with ADHD.

Use of Infant Feeding Tube for Staged Flexor Tendon Reconstruction.

A two-stage flexor tendon reconstruction using a silicone rod in the first stage and a free tendon graft through the pseudo sheath formed around the silicone in the second stage was described by Hunter and Salisbury for a neglected and failed flexor tendon reconstruction. We are describing a technique where we have used an infant feeding tube as a substitute for silicone rods, which substantially reduces the cost of procedure but delivers the same results.

Traumatic posterior cerebral artery occlusion in a 14-month-old child.

Following a head injury, a 14-month-old male presented with neck stiffness and 24 hours later developed bilateral lateral rectus palsies. An unenhanced cerebral computed tomographic scan performed on admission revealed evidence of subarachnoid hemorrhage, cerebral edema, and mild-to-moderate compensated supratentorial hydrocephalus. A second scan performed 96 hours after the head injury revealed a mural thrombus at the tip of the basilar artery without any evidence of infarction. A third scan performed 12 days later revealed that the thrombus had resolved. However, a left posterior cerebral artery territory infarct was visualized. We postulate that the thrombus had embolized to the left posterior cerebral artery and caused occlusion of its cortical branch and subsequent infarction. A magnetic resonance angiography performed 20 days later excluded any vascular abnormality. The bilateral lateral rectus palsies persisted at the 6-month follow-up. To our knowledge, a head injury leading to a posterior cerebral artery territory infarct has not been reported earlier in a young child.