Macrolides versus other antibiotics in pediatric scrub typhus: A meta-analysis.

BACKGROUND: While Doxycycline is the recommended drug for treating scrub typhus, there is a growing trend of using Macrolides and Other antibiotics due to their perceived advantages. In this study, we compared the efficacy of Macrolides versus Other antibiotics in the treatment of pediatric scrub typhus. METHODS: Meta-analysis of randomized controlled trials (RCTs) with GRADE (Grading of Recommendations, Assessment, Development and Evaluation) application. Major databases were searched till 30th December 2022. Children of all age groups were included. Primary outcomes included mortality rate and time to defervescence (h). RESULTS: Of the 103 citations retrieved, 5 trials, including 383 children up to 15 years of age with probable and confirmed cases of scrub typhus, were included. None of the trials reported mortality rate. The pooled results from the trials found no significant difference between Azithromycin and Other antibiotics for any of the outcome measures. The certainty of evidence for the primary outcome was deemed to be of "very low certainty", while the certainty of evidence for the secondary outcomes ranged from "low to moderate certainty". CONCLUSIONS: The current meta-analysis revealed that there was no significant difference between Azithromycin and Other antibiotics (such as Doxycycline and Chloramphenicol) in the treatment of scrub typhus in children. However, it's important to note that the evidence generated for the primary outcome was of "very low certainty". PROSPERO REGISTRATION NUMBER: CRD42021276577.

Clinical, laboratory profile and outcomes in children with snakebite from Eastern India.

Background: Snakebite remains a significant public health problem worldwide, particularly in rural areas with unexpected morbidity and mortality. This study evaluated the clinical, laboratory profile and outcomes in children with snake bites from Eastern India. Methods: This was a retrospective case record-based study between January 2017 and December 2021. The clinical features, complications, laboratory profiles and outcomes were analysed. Results: Thirty children with snake bites were admitted during this study period. There was a male predominance with a ratio of 2.3:1. The mean age of presentation was 10.4 years. About 60% of bites occurred during the rainy season between July and September. Most bites (96%) were on lower limbs, predominantly showing vasculotoxic features followed by neurotoxic and a combined presentation. In this study, around 53% received anti-snake venom (ASV) before reaching our centre; the median time to reach our centre was 13 h. Complications such as acute kidney injury (AKI), cellulitis, shock and coagulation abnormalities were common in those who arrived early (before 6 h) than in those who reached late (after 6 h). Similarly, the mean duration of hospital stay was less for those seeking medical attention early as compared to those reaching late for treatment (4.7 days vs. 7.2 days). Twenty-six out of 30 (86.7%) were discharged without any sequelae, 3 (10%) children were left against medical advice and one died. Conclusions: Snakebite remains a major health problem in children causing significant morbidity and mortality. Children, in general, especially males, are particularly vulnerable because of their playful and explorative nature and considerable time spent in outdoor activities. Preventive measures, education about avoiding traditional first aid methods and early administration of ASV reduce complications, duration of hospital stay and avoid the use of antibiotics.

Comparison of post contrast fluid attenuated inversion recovery, 3D T1-SPACE, and T1W MRI sequences with fat suppression in the diagnosis of infectious meningitis.

OBJECTIVE: To assess the usefulness of post contrast Fluid attenuated inversion recovery (FLAIR), 3D T1-SPACE, and T1W magnetic resonance imaging (MRI) sequences with fat suppression in diagnosis of infectious meningitis. METHODS: 75 patients with clinical suspicion of meningitis were evaluated with post contrast FLAIR (PC-FLAIR), post contrast T1-SPACE (PC-T1-SPACE), and post contrast T1WI (PC-T1WI). Sensitivity, specificity, positive predictive value, and negative predictive value of individual sequences were assessed. RESULTS: The sensitivity of PC-FLAIR (88.4%) was greater than PC-T1-SPACE (85.5%) and PC-T1WI (82.6%), considering cerebrospinal fluid (CSF) analysis as gold standard (p < 0.05). Kappa inter-rater agreement between two radiologists was 0.921 for PC-T1-SPACE, 0.921 for PC-T1WI, and 1.0 for PC-FLAIR with a p value <0.05. Both PC-T1-SPACE and PC-FLAIR performed equally in sulcal space enhancement. PC-T1-SPACE and PC-T1WI performed better in evaluation of pachymeningeal enhancement, ependymal enhancement in cases of ventriculitis, whereas PC-FLAIR was more sensitive in assessment of basal cistern enhancement and enhancement along the cerebellar folia. CONCLUSION: Meningeal enhancement could be better appreciated in PC-FLAIR image than PC-T1WI and PC-T1-SPACE. Enhancement in PC-T1-SPACE was comparable to that of PC-T1WI. Being a T1 based spin echo sequence, PC-T1-SPACE has all the advantages of PC-T1WI in addition to its ability to differentiate meningeal enhancement from leptomeningeal vessels. Hence, PC-T1WI can be replaced by PC-T1-SPACE and PC-FLAIR can be added to routine MRI protocol in suspected case of meningitis.

Effect of body mass index (BMI) on pulmonary functions in children of 6-14 years of age: A cross-sectional study.

Background: Over-weight/obesity is a new global pandemic affecting children with prevalence up to 36%. It is responsible for metabolic syndrome and its future complications in children; however, its effect on lung functions in children is not well studied. Aim: To compare lung function tests [forced expiratory volume in the first second (FEV1), FEV1/forced vital capacity (FVC), FVC, and % predicted] of children with over-weight/obesity to that of normal children. Method: it is a hospital-based cross-sectional study. Children of 6-14 years of age with over-weight [body mass index (BMI) >85th centile] and obesity (BMI >95th centile) attending the pediatrics outpatient department (OPD) were included. Age-matched children attending the OPD during the study period were selected as controls. Demographic and anthropometric details were collected, and pulmonary function tests were carried out in included children. Results: A total of 103 children were included (over-weight/obese = 56, control = 47). The percent predicted (%) FEV1 (86.23 ± 12.84 vs 91.77 ± 8.68) and FVC (81.93 ± 12.12 vs 88.62 ± 10.87) were significantly lower in the obese/over-weight group as compared to control group. A signification negative correlation was found between FEV1 (%) and FVC (%) and that of BMI and waist-hip ratio (WHR). Conclusions: Pulmonary functions (FEV1, FVC) are found to be negatively correlated with BMI and WHR.

Eastern India Collaboration on Multisystem Inflammatory Syndrome in Children (EICOMISC): A Multicenter Observational Study of 134 Cases.

Background: Few single center studies from resource-poor settings have reported about the epidemiology, clinical feature and outcome of multisystem inflammatory syndrome in children (MIS-C). However, larger data from multi-center studies on the same is lacking including from Indian setting. Methods: This retrospective collaborative study constituted of data collected on MIS-C from five tertiary care teaching hospitals from Eastern India. Children ≤ 15 years of age with MIS-C as per the WHO criteria were included. Primary outcome was mortality. Results: A total of 134 MIS-C cases were included (median age, 84 months; males constituted 66.7%). Fever was a universal finding. Rash was present in 40%, and conjunctivitis in 71% cases. Gastro-intestinal and respiratory symptoms were observed in 50.7% and 39.6% cases, respectively. Co-morbidity was present in 23.9% cases. Shock at admission was noted in 35%, and 27.38% required mechanical ventilation. Fifteen (11.2%) children died. The coronary abnormalities got normalized during follow-up in all except in one child. Initial choice of immunomodulation had no effect on the outcomes. Presence of underlying co-morbidity, lymphopenia, thrombocytosis, hyponatremia, increased LDH (>300 U/L), and hypoalbuminemia were the factors significantly associated an increased mortality. Conclusions: MIS-C has myriad of manifestations. Underlying co-morbidity, lymphopenia, thrombocytosis, hyponatremia, increased LDH (>300 U/L), and hypoalbuminemia were associated with an increased mortality. No difference in outcome was noted with either steroid or IVIg or both. Coronary artery abnormalities resolved in nearly all cases.

Role of procalcitonin in diagnosis of community acquired pneumonia in Children.

BACKGROUND: The role of serum Procalcitonin (PCT) in adults in diagnosis of Community acquired pneumonia (CAP) is well established, however, role in pediatric CAP remains controversial. OBJECTIVES: The objective of this study was to investigate the utility of serum procalcitonin in differentiating bacterial community-acquired lower respiratory tract infection from non-bacterial respiratory infection in children; radiologically confirmed pneumonia was used as the reference. In addition, we assessed the utility of adding the PCT assay to the clinical criteria for diagnosis of pneumonia. STUDY DESIGN: Subanalysis of a larger prospective,multicentriccohort study. PARTICIPANTS: Children, 2 months to 59 months of age, attending paediatric OPD of 5 urban tertiary care hospitals, suffering from acute respiratory infection (ARI). INTERVENTION: Detailed clinical history and examination findings of enrolled children were recorded on predesigned case record form. Samples for PCT were obtained at admission and were measured centrally at the end of the study except for one site using VIDAS® B.R.A.H.M.S PCT kit (Biomerieux SA, France). OUTCOMES: Sensitivity and specificity of procalcitonin for diagnosis of radiologically confirmed pneumonia. RESULTS: Serum Procalcitonin was measured in 370 patients; median (IQR) age of these children being 12 (7, 22) months, 235 (63.5%) were boys. The median (IQR) serum procalcitonin concentration was 0.1(0.05, 0.4) ng/mL.Sensitivity and specificity of raised PCT (> 0.5 ng/mL) for pneumonia as per any CXR abnormalities were 29.7% and87.5%,(P < 0.001) respectively. Raised PCT was also significantly associated with consolidation (34.5%,79.2%,P < 0.02)and pleural effusion(54.6%,79%,P < 001). Adding PCT to the existing clinical criteria of WHO did not improve the sensitivity for diagnosis of pneumonia. PCT was significantly higher in children with severe pneumonia. CONCLUSION: Positive PCT (> 0.5 ng/mL) is significantly associated with radiographic pneumonia but not with pneumonia based on WHO criteria.However, it can act as a surrogate marker for severe pneumonia.

Profile of Scrub Typhus Meningitis/Meningoencephalitis in Children with and without Scrub Typhus IgM Antibody in CSF.

The aim of this article was to study the spectrum of scrub typhus meningitis/meningoencephalitis (STM) cases in children. Children ≤14 years of age with acute undifferentiated febrile illness were included. Immunoglobulin M (IgM) enzyme-linked immunosorbent assay was done in blood and cerebrospinal fluid (CSF) of children with suspected STM. Demographic, clinical, and laboratory details were expressed as descriptive statistics. Factors associated with neurological involvement were identified on univariate analysis. A total of 76 children had ST during the study period (meningitis/meningoencephalitis = 8 [10.5%], of which 5 [62.5%] had detectable ST IgM antibodies in CSF). The included children were 4 to 12 years of age with boys > girls. Headache and vomiting were common in those with STM, whereas hyponatremia and thrombocytopenia were common in those without STM. All children with STM recovered with sequelae in one child (right lateral rectus palsy). There was no mortality. STM has an incidence of 10.5% in children with ST from Eastern India. Headache and vomiting were significant predictors of STM, whereas hyponatremia and thrombocytopenia were significant predictor of non-STM.

When the head is big, think this too: Megalencephalic leukoencephalopathy in a toddler with only a large head. A case report.

We present a one-year old, developmentally normal toddler from a non Agarwal community, who presented to us with only a large head. The examination findings were unremarkable except a large head circumference. Neuroimaging confirmed the diagnosis of megalencephalic leukoencephalopathy (MLC). Although developmental delay and seizures are common manifestations in MLC, we want to highlight the fact that many children like ours may have no neurological manifestations at all which makes it necessary to do neuroimaging to establish the diagnosis and offer genetic testing for confirmation of the same.

Prevalence of Insulin Resistance in Urban Indian School Children Who Are Overweight/Obese: A Cross-Sectional Study.

Background: Limited data are available for insulin resistance (IR) in over-weight/obese children from the Indian subcontinent. Identifying predictors of IR in this population is important, as they may be used as a screening tool for future metabolic complications. Materials and Methods: This school-based cross-sectional study was conducted in an Eastern Indian city. Anthropometry and blood pressure measurements were carried out as per the published guidelines. Venous blood samples were taken in a fasting state to measure plasma glucose, insulin, and lipid profile. IR was measured quantitatively by a homeostatic model of assessment (HOMA-IR). Results: A total of 545 (28.2%) children who were overweight or obese were included. The male:female ratio was 1:1.27. The overall prevalence of metabolic syndrome (MS) in these children was 21.8%. Around 32.3% of children had HOMA-IR of ≥2.5, and 22.2% had HOMA-IR of ≥3.16. The mean HOMA-IR in children with MS was 5.46 compared to 2.18 in those without MS. An increased risk of IR with low HDL, high triglyceride, increased waist circumference, and increased BP (both systolic and diastolic) was found. This means that insulin resistance was more common in children who were overweight or obesity and had underlying MS. Conclusions: The present school-based study found a high prevalence of insulin resistance among children who were overweight or obese. This could predict an increased risk of future adverse cardio-vascular events in the studied children. The findings of this study would help in planning and implementing primary prevention programs targeting weight management and lifestyle change in schoolchildren.

Profile and Outcome of Childhood Hydrocarbon Poisoning: An Observational Study.

BACKGROUND:  Accidental poisoning, though preventable, has continued to be one of the most prevalent medical emergencies among children in developing countries. OBJECTIVE: To describe the clinico-demographic profile and outcome of children with hydrocarbon poisoning at a tertiary care teaching hospital from Eastern India. METHODS: A retrospective analysis of the hospital case records of all children <15 years of age admitted with hydrocarbon poisoning from January 2015 to October 2018 was performed. RESULTS: Out of 2658 total admissions, 21 children were admitted with hydrocarbon poisoning during the study period. The median age was 2.6 years (range, 1 to 14 years). Majorities (76%) were <5 years of age. The male/female ratio was 5:2. The majority belonged to rural areas (80.9%) and low socioeconomic status (71.4%). In all the cases, poisoning was accidental in nature. Kerosene (71.4%) and turpentine oil (24%) were the most common agents implicated. Majorities (95.3%) were symptomatic requiring hospitalization. Fever and vomiting were the most commonly observed symptoms (57%). Neutrophilic leucocytosis was observed in 62% of cases. Abnormal chest radiography was observed in 67% of cases. There was no mortality. CONCLUSIONS: The majority of the children with hydrocarbon poisoning are under five years of age with the accidental mode of poisoning in the current study. Kerosene was the most common agent. The outcome was excellent without any mortality.

Clinicopathological Profile and Outcome of Childhood Urticaria Vasculitis: An Observational Study.

Background Urticaria is a type III hypersensitivity reaction usually triggered by an infection, medication, or food item. It usually subsides within 24 hours without any residual lesion and does not have any systemic manifestation. Urticaria vasculitis (UV) is a clinicopathological condition defined by the presence of an urticarial lesion lasting for >24 hours or recurrent episodes of urticaria associated with histopathological features of leukocytoclastic vasculitis. Methods This retrospective study was conducted in a tertiary care teaching institute in Eastern India over a period of 2 and ½ years. Children presenting with urticaria lesions for a duration of > 24 hours that did not subside either spontaneously or with anti-histamines were admitted for further workup and management. Results During the study period (July 2015 to December 2017), a total of 20 children with urticaria needed admission for symptom control and further workup. There were 16 boys and 4 girls. The mean (SD) age of presentation was 6.5 years (±2.4). Besides urticaria in all, pain abdomen was present in 13 (65%) and fever in 6 (30%) children. Only one had arthritis. Skin biopsy performed in these children was suggestive of leukocytoclastic vasculitis. One child was ANA (anti-nuclear antibody) positive with low C3. All except three children required systemic steroid for symptom control along with other medications (anti-histamines). None had suffered any complication or relapse.  Conclusions Urticaria vasculitis (most common cause being idiopathic) remains underdiagnosed because of the need of confirmation by biopsy, which might not always be attempted in every case. Though anti-histamines remain the main stay of treatment, adding short course oral steroid shortens the course once infection is ruled out.

Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study.

BACKGROUND: India has the largest burden of drug­resistant organisms compared with other countries around the world, including multiresistant and extremely drug­resistant tuberculosis and resistant Gram­negative and Gram­positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited. OBJECTIVE: This multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology. METHODS: This hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles. RESULTS: The study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of June 2020, data for 56 humans, 30 animals and birds, and fishes from 10 ponds have been collected. Data analysis is yet to be done. CONCLUSIONS: This study will inform about the bacterial infection and resistance epidemiology among different hosts, the risk factors for infection, and resistance transmission. In addition, it will identify the potential triggers and levers for further exploration and action. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/23241.

Metabolic Syndrome and Insulin Resistance in Schoolchildren From a Developing Country.

Background: Overweight and obesity are prevalent in schoolchildren due to dietary habits and lack of exercise. These children are prone to metabolic syndrome (MS) and future risk of type 2 diabetes mellitus and cardiovascular diseases. Materials and Methods: This cross-sectional study was conducted in Bhubaneswar City, Eastern India, among schoolchildren. Obesity and overweight were determined by the Indian Academy of Pediatrics guideline. Fasting venous blood samples were taken for insulin, blood glucose, and lipid levels measurement. Blood pressure was measured as per the protocol. The International Diabetic Federation (IDF) criteria for the definition of MS were followed. Insulin resistance was determined by a homeostatic model assessment (HOMA-IR). Results: A total of 1,930 children were screened, of which 545 (28.2%) were overweight and obese. The male to female ratio was 1.27. The overall prevalence of MS was 21.8% (11% in 6 to ≤10 years old and 30.6% in 11 to 16 years old). A history of cardiovascular disease, diabetes, obesity, and hypertension in the family was present in 42.7%. Acanthosis nigricans was present in 46.4%. A history of exclusive breast feeding for 6 months was present in 68.1%. The mean HOMA-IR in children with MS was 5.46 compared to 2.18 in those without MS (insulin resistance was more common in children with MS). Conclusions: The present study found a higher prevalence of MS and insulin resistance in schoolchildren from Eastern India who are overweight/obese.

Effect of a Training Strategy in Improving Medication Fallacies During Pediatric Cardiopulmonary Resuscitation: A Before-and-After Study From a Developing Country.

OBJECTIVE: This study aims to evaluate the effect of structured training on resident performance in improving medication fallacies during pediatric cardiopulmonary resuscitation (CPR). METHODS: This before-and-after study was conducted in the pediatric acute care areas of tertiary care teaching hospitals of a developing country from August to December 2015. Case records of children younger than 18 years who underwent CPR were reviewed. Senior residents rotating through pediatric emergency department and pediatric intensive care unit were evaluated for their knowledge. Incidence of medication fallacies in pediatric CPR and change in the knowledge scores of residents posted in these areas were the main outcome measures. RESULTS: One-hundred records were evaluated (pre-intervention, 54; post-intervention, 46). In the pre-intervention period, 25 had medication fallacies (documentation, 16; dosing, 9). In the post-intervention period, 7 fallacies pertaining to documentation (not dosing) were found. The incidence of severe fallacies decreased from 20% pretraining to 0% posttraining. The mean (SD) knowledge scores of residents increased from 7.9 (2.9) pretraining to 13 (1.4) posttraining. On univariate analysis, fallacies were found to be less if the resident was formally trained (pediatric advanced life support certified), if the patient was older, and during morning and night shifts as compared with evening shift. On multivariate analysis, however, only status of training (posttraining) (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.68) and the morning shift (adjusted odds ratio, 0.03; 95% confidence interval, 0.001-0.72) remained significant with lower incidence of fallacies associated with these variables. CONCLUSIONS: Rates of medication fallacies in pediatric CPR declined with structured training. Documentation fallacies may not be eliminated completely with only 1-time training.

Anterior Superior Iliac Spine to the Tibial Tuberosity Length: An Easier, Accurate, and Faster Method for Predicting Orogastric Tube Length in Neonates-An Observational Study.

Orogastric tube (OGT) procedures are done in 20% of newborn unit cases. This study was contemplated to work out a formula to predict OGT length in terms of femur length in neonates and its agreement to existing standards. In this observational study, OGT length was estimated using NEMU (nose-ear-mid umbilicus) in 53 consecutive newborns. Their anterior superior iliac spine to tibial tuberosity length (AS-TT) was measured and equated using linear regression analysis in Stata. We further verified the accuracy of the new formula and comparison of time taken by both the methods. Strong positive correlation was seen between OGT and AS-TT (r = .88). OGT length was 10.14 + 0.88 AS-TT, which can be used in neonatal intensive care unit newborns with greater accuracy and with lesser time than the classical method. Strong agreement levels were seen. AS-TT closely relates to the femur length and can be chosen as a guide as it is faster when compared to other methods.

Immunogenicity and safety of a novel MMR vaccine (live, freeze-dried) containing the Edmonston-Zagreb measles strain, the Hoshino mumps strain, and the RA 27/3 rubella strain: Results of a randomized, comparative, active controlled phase III clinical trial.

This phase III clinical trial was conducted to evaluate the immunogenicity and safety of the single-dose and multi-dose formulations of a novel MMR vaccine (live, freeze-dried) developed by M/s Cadila Healthcare Limited, India (Cadila MMR vaccine), containing the Hoshino mumps strain, compared to that of an existing MMR vaccine (live, freeze-dried) developed by M/s Serum Institute of India Limited, India (Serum MMR vaccine). These two vaccines have similar measles and rubella strains, but different mumps strains (Hoshino in Cadila MMR vaccine, and L-Zagreb in Serum MMR vaccine). Three hundred and twenty-eight subjects of either sex, aged 15-18 months, were randomized in a 2:1 ratio to receive either the Cadila or Serum MMR vaccine. Immunogenicity assessments (IgG antibodies against measles, mumps, and rubella viruses) were done at baseline and 42 d after vaccination. Solicited (local and systemic) and unsolicited adverse events were recorded for up to 42 d following vaccination. The Cadila MMR vaccine was found to be non-inferior to the Serum MMR vaccine in terms of end-of-study proportion of subjects seropositive for anti-measles antibodies (100.0% in both groups), anti-mumps antibodies (94.5% vs. 94.0%), and anti-rubella antibodies (95.5% vs. 91.0%). Both vaccines were well tolerated by all study participants; the most common adverse event reported in both groups was fever, followed by rash. The results of this phase III clinical trial show that the novel Cadila MMR vaccine is non-inferior to the Serum MMR vaccine.

Nitazoxanide in Acute Rotavirus Diarrhea: A Randomized Control Trial from a Developing Country.

Background. Acute diarrhea is one of the leading causes of childhood mortality, with rotavirus being an important pathogen. Nitazoxanide, an antiparasitic agent, has been shown to inhibit rotavirus. Objective. This double-blind, randomized trial was designed to study the role of nitazoxanide in acute rotavirus diarrhea. Methods. Of 174 children (12 months to 5 years) with acute diarrhea, 50 rotavirus positive cases were randomized. The intervention group received syrup nitazoxanide twice daily (100 mg in 12-47 months, 200 mg in ≥4 yr) for 3 days along with standard treatment of diarrhea. Duration of diarrhea was the primary outcome measure. Results. The median duration (hrs) of diarrhea (54 versus 80; 95% CI: -26 [-13.2 to -38.8]) and hospitalization (68 versus 90; 95% CI: -22 [-12.98 to -31.02]) was significantly shorter in the nitazoxanide group. No significant difference was seen in the median duration (hrs) of fever or vomiting or the proportion of children requiring parenteral rehydration. There was no report of any adverse events. Conclusions. Oral nitazoxanide is effective and safe in the management of acute rotavirus diarrhea in Indian children (CTRI REF/2016/10/012507).

Optimising adherence to childhood pneumonia treatment: the design and development of patient instructions and a job aid for amoxicillin dispersible tablets.

INTRODUCTION: Pneumonia is the leading cause of death from infection in children worldwide. Despite global treatment recommendations that call for children with pneumonia to receive amoxicillin dispersible tablets, only one-third of children with pneumonia receive any antibiotics and many do not complete the full course of treatment. Poor adherence to antibiotics may be driven in part by a lack of user-friendly treatment instructions. OBJECTIVE: In order to optimise childhood pneumonia treatment adherence at the community level, we developed a user-friendly product presentation for caregivers and a job aid for healthcare providers (HCPs). This paper aims to document the development process and offers a model for future health communication tools. METHODS: We employed an iterative design process that included document review, key stakeholder interviews, engagement with a graphic designer and pre-testing design concepts among target users in India and Kenya. The consolidated criteria for reporting qualitative research were used in the description of results. RESULTS: Though resources for pneumonia treatment are available in some countries, their content is incomplete and inconsistent with global recommendations. Document review and stakeholder interviews provided the information necessary to convey to caregivers and recommendations for how to present this information. Target users in India and Kenya confirmed the need to support better treatment adherence, recommended specific modifications to design concepts and suggested the development of a companion job aid. There was a consensus among caregivers and HCPs that these tools would be helpful and improve adherence behaviours. CONCLUSIONS: The development of user-friendly instructions for medications for use in low-resource settings is a critically important but time-intensive and resource-intensive process that should involve engagement with target audiences.

Indian carp (Labeo rohita) gall bladder poisoning-report of four cases in a single family.

The ingestion of Indian carp gallbladder may result in transient hepatitis with subsequent acute renal failure. This case series also illustrates the importance of understanding the use and potential serious complications of alternative medicines. So fish gallbladder poisoning should be considered in unexplained acute renal failure in Chinese and Asian patients. We report four family members who developed acute renal failure and toxic hepatitis at the same time following ingestion of raw Indian carp (Labeo rohita) gall bladder.