Wednesday, February 27, 2013

A timely update for Pediatricians on Dengue - Published in Arch. Dis. Children

Dengue Viral Infection in Children

A Perspective

S Balasubramanian, Bala Ramachandran, Sumanth Amperayani
Arch Dis Child. 2012;97(10):907-912. 


Dengue is a vector-borne viral infection of global importance. Several pathogenetic mechanisms such as immune enhancement and selection pressure have been proposed and febrile, critical and recovery phases have been identified. A new classification proposed by WHO has recently been introduced where definitions have been changed to 'probable dengue', 'dengue with warning signs' and 'severe dengue'. The majority of dengue viral infections are self-limiting, but complications have high morbidity and mortality. The diagnosis of dengue viral infection is essentially clinical, although confirmation requires laboratory tests including serology, NS1 antigen detection, PCR and viral cultures. There are no specific anti-dengue drugs and treatment is basically supportive and consists of early recognition of complications and appropriate fluid therapy. A number of candidate vaccines are under development.
For full article go here (requires free medscape registration)

Wednesday, February 20, 2013

Indian cardiologist in the US received more than $100 000 in referral kickbacks

An Indian cardiologist in New Jersey,USA was arrested for having embezzled over Rs. 58 lakhs in kickback over a period of two years for referring patients for MRI and CT scan to a particular centre. He received US$ 100 for MRI and US$ 50 for CT scan. He is likely to face imprisonment and fine as per US laws.
In India, the medical profession is losing its reputation because the general population at large feels that such corrupt practices are also prevalent in Indian medical profession. I personally feel that the State Medical Councils should start taking actions against such people.
A US cardiologist has pleaded guilty to referring patients for diagnostic tests in exchange for money.
From 2009 to 2011, Dr Shashi Agarwal, 60, solicited and received more than $100 000 in kickbacks for referring patients for MRI and CT scans.
He is the 10th person to plead guilty to receiving financial kickbacks for referring patients to Orange Community MRI.
The former executive director of Orange Community MRI, Chirag Patel, 37, admitted paying bribes to physicians since 2008.
Former owner and medical director, Dr Ashok Kumar Barbaria, pleaded guilty to the same charges.
Agarwal, who was in private practice, was paid for each patient he referred for an MRI or CT scan.
He agreed to refer as many as 20 patients a month and he was paid $100 cash for an MRI and $50 for each CT-scan referral.
He is scheduled to be sentenced on June 6, 2013 and could face up to five years in prison and a maximum fine of $250 000. He has agreed to forfeit the $101 750 in bribe money.
Comment: An Indian Doctor has been paying off another Indian Doctor to refer patients for medical tests! This is so prevalent in India, that many private practitioners would not even bat an eyelid if offered a commission for referring a patient. At least this practice will hopefully not rear its ugly head in the US. In India, I do not foresee anything similar happening in the near future though. 

Friday, February 08, 2013

Recurrent idiopathic thrombocytopenic purpura in childhood

I have a 1.5 year old child who came with petechiae (small skin bleeds) around 15 days back. On presentation the platelet counts were ~ 20,000 and we diagnosed the child as ITP (Immune Thrombocytopenic Purpura). The platelet counts improved dramatically after IVIG infusion, and we discharged the child after 2 days. Unusually, the child came back to us after 15 days with recurrent symptoms and again the Platelet counts were ~ 20,000. At this point of time I discussed the case with a Pediatric hemato-oncologist in PGIMER, and was told that nowadays they have become very liberal in NOT treating cases of ITP. According to him, even platelet counts as low as 5-10,000 may not need treatment unless they have active mucosal bleeding, since the risk of serious bleeds remains very low in children with acute ITP. This is certainly something that I was not aware of. In fact he went on to say, that ITP has now probably become a disease of the mind... in the mind of the patient, and in the mind of the doctor. He did agree that this approach was probably difficult for an individual doctor in Private Practice to adopt, but believes that this is the scientifically accurate approach.

Here is an interesting article that I found related to recurrent ITP.
Recurrent idiopathic thrombocytopenic purpura in childhood.
Haemophilia Center-Haemostasis Unit, Aghia Sophia, Children's Hospital, Athens, Greece.

Idiopathic thrombocytopenic purpura (ITP) is a common haematological disease during childhood, that usually has a benign course; however, literature on the recurrent form of the disease (rITP) is limited.

rITP was characterized by intermittent episodes of thrombocytopenia (TP) followed by periods of recovery, unrelated to therapeutic intervention. We retrospectively reviewed features of patients with rITP, diagnosed and systematically followed up at our center, during the period 1975-2004.

Forty-eight of 795 children with ITP (6.0 %) presented with rITP. The majority of patients (68.8%) had only one recurrence, whereas only one patient had four. A time interval between two episodes longer than 3 months (up to 96) was identified in 2/3 of episodes and less than 3 months in 1/3. The initial episode and the first recurrence mostly shared features of acute ITP; however, 22.9% of the episodes appeared with a chronic self-limited course. Bleeding manifestations were rare (18.6% of episodes) and mild, and they tended to occur in severely thrombocytopenic patients, mainly at the onset of the initial episode; intracranial hemorrhage (ICH) occurred in a toddler with short duration thrombocytopenia. Intravenous gamma globulin (IVIG) or corticosteroids were administered in 24.5% of episodes. None of the patients needed splenectomy. Conclusion: rITP is a rare, mild, self-limited type of ITP, although ICH may occur in a profoundly TP child. Recurrence may occur close or far apart to a previous isolated TP episode. The duration of episodes varies considerably from patient to patient and from episode to episode in the same patient. The pathogenesis of rITP still remains unclear. 

Pediatr Blood Cancer. 2008 Aug;51(2):261-4. doi: 10.1002/pbc.21569.

Comments: What I found interesting was the fact that 6 % kids with ITP would have recurrence, and 1/3rd would have recurrence within 3 months. Also rITP has a good prognosis in general, and serious bleeds are very rare. I believe that it is important to counsel parents regarding the uncommon risk of recurrent thrombocytopenia in this situation, especially when expensive treatment like IVIG is given to the patient.

Swine Flu is back in North India, but no need to panic

57 cases of Swine Flu have been recorded in Delhi with three deaths.
Do not panic as this does not mean that for every 57 cases, three will die. This only means that 57 laboratory confirmed cases have been reported. There will be a large number of who have not got tested.
Mortality is high in patients who are pregnant or have underlying heart disease or other organ damage disease. Routine people do not have to worry.
  • Swine flu presents with fever of more than 1000F with cough or sore throat in the absence of any other main cause.
  • The diagnosis is confirmed with a lab test using rRT/PCR technique.
  • Mild or uncomplicated flu or Swine Flu is characterized by fever, cough, sore throat, nasal discharge, muscle pain, headache, chills, malaise and sometimes diarrhea and vomiting. In mild cases, there is no shortness of breath.
  • Progressive swine flu is characterized by above symptoms along with chest pain, increased respiratory rate, decreased oxygen in the blood, labored breathing in children, low blood pressure, confusion, altered mental status, severe dehydration and exacerbation of underlying asthma, renal failure, diabetes, heart failure, angina or COPD.
  • Severe or complicated swine flu is characterized by respiratory failure, requirement of oxygen or ventilator, abnormal chest x-ray, inflammation of the brain, lowering of blood pressure to less than 60 and involvement of the heart muscle. These patients will have persistent high fever and other symptoms lasting more than three days.
  • Most patients will remain asthmatic with illness lasting 3-7 days.
  • The other characteristic features are presence of chills, muscle pain and joint pain.
  • In the pregnant women, flu can cause more serious complications including death of fetus.
  • Patients at extreme of ages are at risk. Mild cases do not require admission but progressive cases need to be admitted.
  • Older age, underlying, organ disease and requirement of mechanical ventilation is the indication for admission.
  • Tamiflu (oseltamivir phosphate) is the treatment of choice but it should be taken under medical supervision. But it has to be given in the first 48 hours. It is given in severely low patients, pregnant women, underlying organ disease or age less than 5 and more than 65 years.
  • Flu vaccine can be given to all. It should be given to all high-risk patients.
  • The virus spreads through droplet infection and spreads with a person coughs, sneezes, sings or speaks. The virus can cover only a distance of 3 to 6 feet.
  • Stay 3 feet away from the person who is coughing.
The standard prevention is respiratory hygiene, cough etiquette and hand hygiene.
  • Hand washing should be performed before and after every patient contact or infectious material and before putting and after removing gloves.
  • Hand hygiene can be performed by washing with soap, water and with alcohol based hand drops.
  • If hands are visibly soiled, they should be washed with soap and water.
  • Patients should be placed in a private room or area. The health care staff should wear a face mask while entering the patient’s room. When leaving the room, the health care workers should remove the face mask, dispose it off and then perform hand hygiene.
  • Patients should wear a surgical mask and should be aware of respiratory hygiene, cough etiquette and hand hygiene.
  • Droplet precaution should be taken for seven days after illness onset or 24 hours after resolutions of fever and respiratory syndrome.
  • One should not cough in the hands, handkerchief but instead cough either in the tissue paper and dispose it off or in the side of the arm.

Comments: I am again suggesting to all my patients & their parents to take the Influenza vaccine. It has been shown to prevent serious Flu disease in around 70 % of people who have taken the vaccine, and is well tolerated and safe. If you want to prevent yourself from catching this serious & life threatening condition, it is certainly important to consider taking this vaccine. Do remember, you need to take one dose every year to maintain the protection, though children (less than 9 years age) require two doses when they take it for the first time.