Vitamin D status among Kashmiri tribal population: A cross-sectional community-based study.

Background & objectives: Vitamin D deficiency (VDD) is prevalent across all age groups in general population of India but studies among tribal populations are scanty. This study aimed to evaluate the prevalence of VDD in the indigenous tribal population of the Kashmir valley and examine associated risk factors. Methods: In this cross-sectional investigation, a total of 1732 apparently healthy tribal participants (n=786 males and n=946 females) were sampled from five districts of Kashmir valley by using probability proportional to size method. Serum 25-hydroxy vitamin D (25(OH)D) levels were classified as per the Endocrine Society (ES) recommendations: deficiency (<20 ng/ml), insufficiency (20-30 ng/ml) and sufficiency (>30 ng/ml). The serum 25(OH)D levels were assessed in relation to various demographic characteristics such as age, sex, education, smoking, sun exposure, body mass index and physical activity. Results: The mean age of the male participants was 43.79±18.47 yr with a mean body mass index (BMI) of 20.50±7.53 kg/m[2], while the mean age of female participants was 35.47±14.92 yr with mean BMI of 22.24±4.73 kg/m2. As per the ES guidelines 1143 of 1732 (66%) subjects had VDD, 254 (14.71%) had insufficient and 334 (19.3%) had sufficient serum 25(OH)D levels. VDD was equally prevalent in male and female participants. Serum 25(OH)D levels correlated positively with serum calcium, phosphorous and negatively with serum alkaline phosphatase. Gender, sun exposure, altitude, physical activity and BMI did not seem to contribute significantly to VDD risk. Interpretation & conclusions: VD deficiency is highly prevalent among Kashmiri tribals, although the magnitude seems to be lower as compared to the general population. These preliminary data are likely to pave way for further studies analyzing the impact of vitamin D supplementation with analysis of functional outcomes.

Risk of Hospitalization in Under-five Children With Community-Acquired Pneumonia: A Multicentric Prospective Cohort Study.

OBJECTIVE: To evaluate factors associated with risk of hospitalization in children with community-acquired pneumonia (CAP). DESIGN: Prospective cohort study. SETTING: Multi-site hospital based study. INTERVENTION: A separate acute respiratory tract infection (ARI) treatment unit (ATU) was established. The revised WHO case definition for ARI was used across all the study sites to ensure uniformity in management of ARI patients (2-59 months). Clinical history, examination findings and investigations of enrolled patients were recorded on a predesigned case record form. Children were followed up at 1 week (± 1 day). MAIN OUTCOME MEASURE: Risk factors for hospitalization among pneumonia patients. RESULTS: A total of 7026 children with the diagnosis of ARI were enrolled. Pneumonia was diagnosed in 938 (13.4%) patients (median (IQR) age: 15 (8, 25) months; 63.5% boys). Hospitalization was needed in 56.8% of pneumonia patients. On multi-variate analysis, factors associated with risk of hospitalization were: Oxygen saturation on pulse oximetry (SpO2) <92% in room air (OR 7.04; 95% CI 1.6, 30.8, P=0.01), procalcitonin level >0.5 ng/mL (OR: 7.5, 95% CI: 1.0, 57.7, P=0.05), and lower weight for height z-score (OR 0.8; 95% CI: 0.6, 0.9, P=0.02). CONCLUSION: Present study found SpO2 <92% at room air, serum procalcitonin level >0.5 ng/mL and lower weight for height z-score to be predictors for risk of hospitalization in under-five children presenting with community acquired pneumonia. These factors can be utilized to assess a child with CAP regarding the need of hospitalization.

Thyroid Function, Urinary Iodine, and Thyroid Antibody Status Among the Tribal Population of Kashmir Valley: Data From Endemic Zone of a Sub-Himalayan Region.

Background: There are scarce data on the prevalence of thyroid disorders and urinary iodine status among tribal populations of India, with no reported data from Kashmir valley. Objectives: To estimate the prevalence of thyroid disorders and evaluate urinary iodine concentration (UIC) and thyroid autoantibody status among Gujjar and Bakerwal tribes of Kashmir valley. Methods: This cross-sectional study recruited tribal subjects using multistage cluster sampling from 5 out of 22 districts of Jammu and Kashmir (J&K). Using a predesigned questionnaire, the details of past or current medical history and drug intake, including thyroid hormone medication etc. were recorded after obtaining an informed consent. Examination included anthropometry (height, weight, waist circumference), blood pressure measurement, and relevant general physical examination focusing on goiter palpation, while as laboratory assessment included estimation of serum thyroid hormone levels, antithyroid peroxidase antibody (anti-TPO Ab), and urinary iodine concentration. Results: A total of 763 subjects (56.4% women and 43.6% men) with a mean(±SD) age of 39.46 (±17.51) ranging from 10 to 85 years and mean(±SD) body mass index (BMI) of 21.28 (±4.16) kg/m2 were studied. Goiter was detected in 6.8%, while 33.2% subjects had some form of thyroid dysfunction (including 24.1% subclinical and 6.8% overt hypothyroidism). Subclinical and overt hyperthyroidism were observed in 1.3 and 0.9% of cases, respectively. Anti-TPO Ab was elevated in 13.6%, while the median [interquartile range (IQR)] for UIC was 154.50 (135) µg/L [156.13 (134) µg/L in men and 147.26 (136) µg/L in women]. A negative correlation was observed between UIC and anti-TPO Ab (r = -0.087, P = <0.05). Conclusion: These novel data on iodine and thyroid status among a tribal population of India generally inhabiting in remote sub-Himalayan belts demonstrate high prevalence of subclinical hypothyroidism (SCH) with persistent iodine deficiency. These preliminary data may warrant large well-designed studies to carry out comprehensive assessment of the problem in this high-risk and marginalized population.

Role of Flexible Bronchoscopy in Ventilator-Dependent Neonates.

OBJECTIVE: To assess the usefulness and safety of flexible bronchoscopy in ventilated neonates with extubation failure. METHODS: This was a prospective observational study. Flexible bronchoscopy was done in eligible patients with failure of extubation form invasive ventilation. The main outcome measure was to find the presence of any anatomic or dynamic abnormalities of the airways of these patients and the organism profile of bronchoalveolar lavage (BAL) fluid. RESULTS: Forty-eight babies (68.8% preterm) were enrolled in the study. The most common finding on bronchoscopy was airway edema seen in 13 (27%) patients. BAL culture was positive in 29 (74%) patients. Overall treatment was modified in 35 (73%) patients based on bronchoscopy findings/BAL culture. Majority of infants (83.3%) tolerated the procedure very well. CONCLUSIONS: Flexible bronchoscopy provides useful information in the management of newborn babies with extubation failure.

Proceduralist Given Sedation is Safe and Feasible in Pediatric Flexible Bronchoscopy.

The objective of this research was to study the effectiveness and safety of proceduralist given sedation in pediatric flexible bronchoscopy. Flexible bronchoscopy was performed in all 267 patients. All patients received midazolam and/or ketamine. The median (interquartile range [IQR]) age of the studied population was 16 (18) months. The indication of bronchoscopy varied. The mean ± standard deviation (SD) dose of midazolam was 0.109 (0.03) mg/kg and that of ketamine was 1.17 (0.43) mg/kg. We observed minor side effects of procedural sedation. All patients underwent procedure successfully. Flexible bronchoscopy in children can be safely performed under sedation using a combination of midazolam and ketamine.

Prevalence of Depression among Caregivers of Indian Children with Cystic Fibrosis.

OBJECTIVE: To study the prevalence of depression among caregivers of children with cystic fibrosis and its impact on the health and well being of these children. METHODS: This cross-sectional study was conducted in a tertiary care hospital from September 2015 through August 2016. Forty one parents of children receiving treatment at the Cystic fibrosis (CF) clinic were approached to be part of the study. Six families declined the request resulting in 85% recruitment rate. The Centre for Epidemiological Studies Depression Scale (CES-D) was used to assess depression score among caregivers. The CES-D provides clinical cut-off scores of ≥16 that help in identifying persons at risk for depression. CES-D was completed by the parent closely associated with care of the affected child. Main outcome measure was to find the number of caregivers of patients who has score of ≥16 on CES-D scale, and its effect on growth and respiratory exacerbations of the affected child. RESULTS: A total of 23 fathers and 12 mothers participated in the study. The mean age of male and female caregivers was 30.9 ± 5.4 and 27.8 ± 4.7 y respectively. Eighteen (51.4%) caregivers scored above the clinical cut-off on the CES-D in the index study with mean score of 22.0 ± 4.0. The mean CES-D score among non-depressive caregivers was 7.76 ± 4.2. Significant negative association was found between parental depression and child's health. Children with high parental CES-D score suffered significantly more respiratory exacerbations (3.83 ± 1.2 episodes) in last six months than parents with low CES-D score (2.18 ± 1.28 episodes) (p value = 0.00). Similarly, stunting was more commonly seen in patients with high caregiver CES-D score (15 vs. 7; P value = 0.01). CONCLUSIONS: A very high prevalence of caregiver depression was found in cystic fibrosis, which negatively impacted care and well being of the affected patients. Depression was more common in families with poor economic and education level.

Clinical Spectrum of Disorders of Sex Development: A Cross-sectional Observational Study.

OBJECTIVE: Disorders of sex development (DSD) constitutes a small but difficult and equally important area of endocrinology. It is often a social emergency as the decision regarding sex assignment in these cases is extremely disturbing and difficult to both families and healthcare professionals. Our study was devised to assess the clinical and chromosomal profile of patients with suspected DSD and classify them according to the new DSD consensus document. SUBJECTS AND METHODS: This study was a cross-sectional observational study carried out in the department of pediatrics of a tertiary care hospital from August 2012 to August 2014. All patients with suspected DSD in the age group of 0-19 years were included. After detailed history and examination, karyotyping, abdominal sonography, and hormonal analysis were done. Additional studies like gonadal biopsy, laparoscopy, and hormone stimulation tests were done in selected cases. RESULTS: About 41 patients were included in the study. The mean age of presentation was 87 months (1 day to 16 years). Only seven (13.7%) patients presented in neonatal period. In total, 25 patients had ambiguous genitalia; 46, XX DSD were diagnosed in 24 (58.5%) patients, 46, XY DSD in 10 (24.4%) patients, and sex chromosome DSD in 7 (17.1%). Congenital adrenal hyperplasia (CAH) was the commonest disease diagnosed in 21 (51.2%) patients. Turner syndrome, Klinefelter syndrome, androgen insensitivity syndrome, 46, XX ovotesticular disorder, and 46, XY gonadal dysgenesis were diagnosed in 3, 3, 4, 3, and 5 patients, respectively. Eleven patients with CAH presented in shock and six had history of sib deaths. CONCLUSION: 46, XX DSD were the commonest etiological group in our study and CAH was the commonest individual disease. There is a need for educating general public and practitioners regarding DSD to allow early intervention. Moreover, there is a need to introduce routine neonatal screening for CAH in our country.

Maternal Overt Hypothyroidism and Neurobehavioral Outcome of Neonates: A Cohort Study from an Iodine-deficient Area of Northern India.

OBJECTIVE: To study the relation between maternal overt hypothyroidism and neurodevelopmental outcome of neonates in iodine-deficient region of Northern India (Kashmir Valley). DESIGN: Prospective cohort study. SETTING: Endocrinology department of a tertiary-care hospital. PARTICIPANTS: 82 hypothyroid pregnant women were enrolled and followed up till delivery. The neonates born to this group represented the case neonates. 51 euthyroid healthy pregnant women were selected as control group. The neonates born to these mothers served as controls. MAIN OUTCOME MEASURES: Early neonatal behavioral assessment at 3-4 weeks of age. RESULTS: The mean TSH and free T4 in neonates of mothers with well controlled hypothyroidism was significantly different from those born to mothers with poorly controlled hypothyroidism and controls in 1st trimester, but the difference was statistically insignificant for 2nd and 3rd trimester values. CONCLUSION: Overt maternal hypothyroidism in iodine-deficient area constitutes a risk factor for an abnormal neurobehavioral development of affected child.

Neonatal mechanical ventilation: Indications and outcome.

BACKGROUND AND AIMS: Decreasing mortality in sick and ventilated neonates is an endeavor of all neonatologists. To reduce the high mortality in this group of neonates, identification of risk factors is important. This study was undertaken to find out the indications of ventilation and complications in ventilated neonates and also study possible predictors of outcome. SUBJECTS: Age <1-month; mechanically ventilated; not having suspected metabolic disorders or congenital anomalies; excluding postoperative patients. METHODS: Neonates consecutively put on mechanical ventilation during the study period (October 2011 to November 2013) enrolled. Primary disease of the neonates along with complications present listed. Clinical and laboratory parameters analyzed to find the predictors of mortality. RESULTS: Total 300 neonates were ventilated. 52% were male. Mean age, weight, and gestational age were 21 ± 62 h, 2320 ± 846.2 g, and 35.2 ± 4.9 weeks, respectively. 130 (43%) neonates died. Respiratory distress syndrome (RDS) (31.1%), sepsis (22.7%), and birth asphyxia (18%) were the most common indications for ventilation. Mortality in ventilated patients with sepsis, pneumonia, RDS or birth asphyxia was 64.7%, 60%, 44.6%, and 33.3%, respectively. Weight <2500 g, gestation <34 weeks, initial pH <7.1, presence of sepsis, apnea, shock, pulmonary hemorrhage, hypoglycemia, neutropenia, and thrombocytopenia were significantly associated with mortality (P < 0.05). Resuscitation at birth, seizures, intra ventricular hemorrhage, pneumothorax, ventilator-associated pneumonia, PO2, or PCO2 did not have a significant association with mortality. On logistic regression, gestation <34 weeks, initial pH <7.1, pulmonary hemorrhage, or shock were independently significant predictors of mortality. CONCLUSIONS: Weight <2500 g, gestation <34 weeks, initial arterial pH <7.1, shock, pulmonary hemorrhage, apnea, hypoglycemia, neutropenia, and thrombocytopenia were significant predictors of mortality in ventilated neonates.

Profile of acute renal failure in children in Kashmir.

We report on the etiology and the short term outcome (3 month) of children with acute renal failure (ARF) at a tertiary care centre in north India. Acute tubular necrosis was the commonest cause of ARF (33%) especially in children <5 years of age; while in children >10 years, glomerulonephritis was the commonest cause. The overall mortality rate was 20%.The outcome at 3 months showed normal renal function in 72 patients and CKD in 5 patients. Three patients were lost to follow-up.

Experience with oral mexiletine in primary erythromelalgia in children.

Primary erythromelalgia is characterized by burning pain, redness, and warmth in the extremities. We present two cases of primary erythromelalgia both of whom presented with a history of several months of severe burning pain in both hands and feet. Both patients had received multiple pain medications with no improvement in symptoms. Pain was relieved by putting affected parts in ice cold water, which resulted in immersion injury of the affected parts. Both patients stopped taking part in school and social activities. We tried oral mexiletine, a class Ib antiarrythmic agent, in view of its reported role in various chronic painful conditions. Dramatic improvement was observed with its use. Both patients improved after several weeks of use, and there were fewer soaking episodes. We observed no adverse effects with mexilitine therapy.

Nosocomial sepsis-induced late onset thrombocytopenia in a neonatal tertiary care unit: a prospective study.

BACKGROUND AND OBJECTIVES: Late onset sepsis (LOS)( onset of sepsis >72 hours of age or nosocomial sepsis) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). Thrombocytopenia is an important complication of sepsis. We investigated the incidence of thrombocytopenia in LOS patients and studied the influence of various parameters on platelet response. PATIENTS AND METHODS: Infants born in the level 3 neonatal intensive care unit between January 2002 and December 2006 with documented LOS were included in this prospective study. Multiple hemograms with platelet counts, bacterial blood culture and fungal blood culture were obtained in all patients. Demographic and clinical data were compared between patients without thrombocytopenia and with mild, moderate and severe thrombocytopenia. Duration of thrombocytopenia in relation to type of organism and mortality with respect to degree of thrombocytopenia were also studied. RESULTS: Of 200 patients with culture-proven nosocomial sepsis, 119 (59.5%) patients developed thrombocytopenia (platelet count <150 X 109/L). In our series Klebsiella pneumoniae was the most frequently isolated organism (125/200, 62.5%) and the incidence of thrombocytopenia was 60.0% (75/125). However, the incidence of thrombo- cytopenia was highest among patients who had concurrent bacterial and fungal sepsis (28/31, 90.3%). Coagulase- negative staphylococcal (CoNS) sepsis was present in 21 (10.5%) patients and the incidence of thrombocytopenia was 33.3%. Isolated fungal sepsis was present only in 6 (3%) patients and the incidence of thrombocytopenia was 66.0%. The incidence of thrombocytopenia was highest among preterm babies and low-birth weight (LBW) babies. Twenty-seven percent (54/200) of babies presented with mild thrombocytopenia, 20% (40/200) presented with moderate thrombocytopenia, and 12.5%(25/200) developed severe thrombocytopenia. Severity of thrombocytopenia was also directly related to the presence of necrotizing enterocolitis (NEC) and disseminated intravascular coagulation (DIC). The mortality rate was significantly associated with the degree of thrombocytopenia. CONCLUSION: LOS sepsis is an important risk factor for thrombocytopenia in the NICU. Fungal and gram- negative sepsis are frequently associated with a decreased platelet count. Sepsis-induced thrombocytopenia is more common among LBW babies and preterm babies. The mortality rate is significantly related to degree of thrombocytopenia.