Teleconsultation for Children With Developmental Disabilities During the Coronavirus Pandemic: Caregivers' Experience.

Background The unprecedented situation due to the coronavirus disease 2019 (COVID-19) lockdown necessitated the need for teleconsultations with caregivers of children with disabilities. The objective of this study was to explore the acceptability, satisfaction, perceived relevance, and barriers to teleconsultation from a caregiver's perspective. Methodology This was a descriptive qualitative study (telephonic interviews) involving in-depth interviews (IDIs) with the caregivers of children with developmental disabilities who received teleconsultations. Manual content analysis of transcripts of IDIs was done. Results Eight IDIs were conducted with the caregivers of children with cerebral palsy, autism, and developmental delay. The respondents expressed increased challenges in managing their children during the pandemic and the need for professional consultation. They also expressed difficulty in accessing professional help during the pandemic due to poor healthcare access and fear of getting COVID-19. The following responses were noted: "For almost a year we couldn't take her for the therapy," "We were unable to take him to therapy which resulted in an increase in tightness of his limbs, and he became more irritable." All respondents preferred video teleconsultations during lockdown due to flexible timings, ease of communication, and no travel restrictions; "I can benefit from teleconsultation because she does not have any physical problem." However, caregivers of children with physical ailments preferred face-to-face consultation. Conclusions Teleconsultation was found to effectively support the treatment and rehabilitation of children with disabilities during the COVID-19 lockdown, although direct face-to-face consultation was preferred by caregivers of children with physical ailments. The use of modern mobile/digital technologies creates new opportunities to improve the quality and accessibility of such services.

Early Interventions for Infants at Risk for Developmental Impairment: The South Asian Perspective.

Majority of under-five children with developmental disabilities live in low- and middle-income countries (LMIC). A considerable proportion of disabilities results from perinatal adversities. The neonatal and infant mortality rates in India, Bangladesh, and Sri Lanka have improved over the last two decades, implying survival of infants at risk for developmental impairments. The need to thrive beyond survival is a well-recognized concept and it is imperative to establish high-risk infant follow-up (HRIF) programmes to capture these infants within the first 1000 d of life. Many challenges are present within the LMICs to identify infants at risk and to ensure early intervention (EI) during the window of optimal neural plasticity. However, it is essential to acknowledge the strengths within such systems to understand the impact of these programmes and packages on the activity and participation of these infants and their families. The International Classification of Functioning, Health and Disability for Children and Youth (ICF-CY) version is a holistic framework that will enable the families, clinicians, and policymakers to measure the impact of these interventions. Though all three countries have national policies to reach for high-risk infants, there is lack of published evidence on the successful implementation of such strategies. Therefore, it is timely to establish universally accessible, culturally appropriate and sustainable HRIF programmes. It is also recommended to measure the outcomes of such programmes based on the ICF-CY to understand the impact on the activity and participation of children in South Asia.

The Spectrum of Clinical, Immunological, and Molecular Findings in Familial Hemophagocytic Lymphohistiocytosis: Experience From India.

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 76 different disease-causing mutations including 39 (51%) novel mutations in PRF1, UNC13D, STX11, and STXBP2 genes. Overall, survival was poor (28%) irrespective of the age of onset or the type of mutation in our cohort. Altogether, this article sheds light on the current scenario of FHL in India. Our data reveal a wide genetic heterogeneity of FHL in the Indian population and confirms the poor prognosis of FHL. This study also emphasizes that though mutational analysis is important for diagnostic confirmation of FHL, flow cytometry based assays help significantly in rapid diagnosis and functional validation of novel variants identified.

Antibiotic Resistance - A Cause for Reemergence of Infections.

This article can rightly be called 'the rise of the microbial phoenix'; for, all the microbial infections whose doomsday was predicted with the discovery of antibiotics, have thumbed their noses at mankind and reemerged phoenix like. The hubris generated by Sir Alexander Fleming's discovery of Penicillin in 1928, exemplified best by the comment by William H Stewart, the US Surgeon General in 1967, "It is time to close the books on infectious diseases" has been replaced by the realisation that the threat of antibiotic resistance is, in the words of the Chief Medical Officer of England, Dame Sally Davies, "just as important and deadly as climate change and international terrorism". Antimicrobial resistance threatens to negate all the major medical advances of the last century because antimicrobial use is linked to many other fields like organ transplantation and cancer chemotherapy. Antibiotic resistance genes have been there since ancient times in response to naturally occurring antibiotics. Modern medicine has only driven further evolution of antimicrobial resistance by use, misuse, overuse and abuse of antibiotics. Resistant bacteria proliferate by natural selection when their drug sensitive comrades are removed by antibiotics. In this article the authors discuss the various causes of antimicrobial resistance and dwell in some detail on antibiotic resistance in gram-positive and gram-negative organisms. Finally they stress on the important role clinicians have in limiting the development and spread of antimicrobial resistance.

Umbilical cord milking for neonates who are depressed at birth: a randomized trial of feasibility.

OBJECTIVE: To evaluate the feasibility and safety of umbilical cord milking (UCM) in neonates who are depressed at birth. STUDY DESIGN: This is a quasi-randomized, non-blinded, controlled trial on infants (≥35 weeks) who were depressed at birth. UCM (cord milked three times) was performed during the even months and the neonates born during the odd months were in the control group. Primary outcome was feasibility and safety. RESULTS: A total of 101 infants were enrolled (50 UCM group and 51 control group) between January 2015 and October 2016. UCM was performed in 95% of infants (59/62) who qualified to receive UCM. There were no significant differences in resuscitation delay, resuscitation efforts, and short-term outcomes between the two groups. CONCLUSIONS: UCM is feasible for term and late preterm infants who are depressed at birth. A larger clinical trial is needed to evaluate long-term benefits of UCM in neonates with HIE.

Utility of Low Fidelity Manikins for Learning High Quality Chest Compressions.

OBJECTIVES: Primarily, to measure the adequacy of chest compression depth after training on low fidelity manikins and secondarily to assess the comparative experience of the learners on high fidelity and low fidelity simulators. METHODS: An observational cohort study in which seventy-two first year postgraduate students underwent a Basic Life Support (BLS) workshop conducted by AHA accredited BLS trainers and they were then required to perform on a high fidelity manikin to objectively record the quality of their performance. RESULTS: There were 34 (47.22%) male and 38 (52.77%) female participants. CPR skills, as judged by checklist of sequential actions and visual inspection during the BLS training on low fidelity simulators (LFS) were correctly performed by majority (95.89%) participants. However, none of the participants could achieve the recommended depth for high quality chest compressions. The participants' perception of degree of realism and their practical experience on both the types of manikins were similar. CONCLUSIONS: Low fidelity manikins are useful for training CPR in sequential manner but fail to impart quality of chest compressions as per AHA recommendations.

Iron deficiency anemia in children.

Iron deficiency is not just anemia; it can be responsible for a long list of other manifestations. This topic is of great importance, especially in infancy and early childhood, for a variety of reasons. Firstly, iron need is maximum in this period. Secondly, diet in infancy is usually deficient in iron. Thirdly and most importantly, iron deficiency at this age can result in neurodevelopmental and cognitive deficits, which may not be reversible. Hypochromia and microcytosis in a complete blood count (CBC) makes iron deficiency anemia (IDA) most likely diagnosis. Absence of response to iron should make us look for other differential diagnosis like ß thalassemia trait and anemia of chronic disease. Celiac disease is the most important cause of true IDA not responding to oral iron therapy. While oral ferrous sulphate is the cheapest and most effective therapy for IDA, simple nonpharmacological and pharmacological measures can go a long way in prevention of iron deficiency.

Is knowledge of medicolegal issues concordant with heightened risk among doctors?

Spurred by the wave of consumerism, patients do not hesitate to drag the doctor to the court. It has now become essential for doctors to educate themselves on the laws relevant to medical practice. This study addresses some of the issues. Doctors in private practice, belonging to different specialities, were given a self administered questionnaire which was then analysed by the percentage of responses to each question. Only 3% of the respondents faced medicolegal problems at the time of the study. All of them were fighting charges of negligence from their patients. Most (97%) did not keep records of patients seen in outpatient services, 63% used consent forms written in English only and 78% took blanket consent forms for procedures; 97% were not aware of any laws protecting them in their practice. This study highlights the gross ignorance of medicolegal issues among doctors and the need for compulsory certificate courses for them and changes in the curriculum for the postgraduates with respect to this important aspect of medical profession.

DOOR syndrome.

DOOR syndrome is a rare multisystem genetic disorder, consisting of deafness (sensorineural), onychodystrophy, osteodystrophy, and mental retardation. Seizures reported frequently in this condition are often refractory to treatment.

Elephantine but not elephantiasis: Subcutaneous zygomycosis.

Subcutaneous zygomycosis is an unusual disorder caused by a rare fungus, Basidiobolus ranarum. We report this entity in a 4- yr- old boy. Biopsy showed the Splendore Hoeppli phenomenon and the culture yielded Basidiobolus ranarum. The child responded to saturated solution of potassium iodide within 1 month of starting treatment.

Rickets in exclusively breast fed babies.

Articles appear periodically in Indian and western literature, about occurrence of vitamin D deficiency in exclusively breast fed babies. Some countries have formulated guidelines for prevention of vitamin D deficiency in such babies. In this study, twenty cases of nutritional rickets were diagnosed in exclusively breast fed babies between December 2003 and December 2006. None of them received vitamin D supplementation. Through this study, we hope to initiate further research and debate among the policymakers on whether or not vitamin supplementation should be given to all exclusively breast fed babies and lead to a formulation of clear cut guidelines in the Indian context.

Panayiotopoulos syndrome.

Panayiotopoulos syndrome is a benign childhood epileptic illness characterized by episodic autonomic symptoms. We present a 9 year old boy with this condition, who presented with episodes of severe vomiting, fever, deviation of eyes and altered sensorium, characteristic EEG in the form of multiple occipital spikes and normal neuroradiologic and metabolic investigations.

Infliximab treatment in refractory Kawasaki syndrome.

Kawasaki syndrome is one of the commonest vasculitides in pediatric age group with devastating consequences if not treated early. Intravenous Gammaglobulin leads to rapid amelioration of clinical symptoms and significantly decreases the risk of development of coronary artery aneurysms. Occasionally, Kawasaki disease may be resistant to I/V IgG. We present our experience with one such patient who ultimately respondend to infliximab therapy.

Breastfeeding programme--right policy, wrong target?

To assess the knowledge of breastfeeding management among obstetriciansand the practices being followed in their hospital, 50 obstetricians in private practice in Nagpur, responded to questionnaires having 6 points covering the entire gamut of common issues regarding breastfeeding. All believed that breast milk is best for the baby. It was found that knowledge about various aspects of breastfeeding management is very poor. Unawareness about the adequacy of colostrum for a full term appropriate for date baby was almost universal. While the policy of promoting breastfeeding every year through public programmes is appropriate, the question is who should be the target? Prospective mothers or obstetricians? It is obvious from this study that obstetricians have significant educational needs in the area of breastfeeding management.