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Gulani A.,Sitaram Bhartia Institute of Science and Research
Cochrane database of systematic reviews (Online)

Otitis media (OM) is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long-term hearing loss caused by this condition, 90% of them in low-income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent OM. To evaluate whether zinc supplements prevent OM in adults and children of different ages. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 1) which includes the Cochrane Acute Respiratory Infections Groups' Specialised Register, MEDLINE (1950 to February week 1, 2012) and EMBASE (1974 to February 2012). Randomised, placebo-controlled trials of zinc supplements given at least once a week for at least a month for preventing OM. Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There was a total of 6820 participants. In trials of healthy children living in low-income communities, two trials did not demonstrate a significant difference between the zinc supplemented and placebo groups in the numbers of participants experiencing an episode of definite OM during follow-up (3191 participants); another trial showed a significantly lower incidence rate of OM in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of OM (mean difference (MD) -1.12 episodes, 95% CI -2.21 to -0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Evidence on whether zinc supplementation can reduce the incidence of OM in healthy children under the age of five years living in low- and middle-income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition) but this is based on one small trial and should therefore be treated with caution. Source

Tandon R.,Sitaram Bhartia Institute of Science and Research
Annals of Pediatric Cardiology

Despite identifying that rheumatic fever (RF) is the result of an immunological reaction following group-A beta-hemolytic streptococcal infection, the pathogenesis remains elusive. RF has been incorrectly designated as causing pancarditis, since it does not cause myocarditis. Research directed toward myocarditis, targeting myosin to unravel the pathogenesis has not succeeded in more than 60 years. RF causes permanent damage to cardiac valves. The mitral valve (MV), derived from the wall of the left ventricle, is composed of a central core of connective tissue, covered on both sides by endothelium. The left ventricle does not have either myocardial or intermyocardial connective tissue involvement in RF. By exclusion, therefore, the primary site of RF damage appears to be the endothelium. Evaluation of the histopathology and immunopathology indicates that RF is a disease of the valvular and vascular endothelium. It is not a connective tissue disorder. Research to identify pathogenesis needs to be focused toward valvular endothelium. Source

Kumar R.K.,Amrita Institute of Medical science and Research Center | Tandon R.,Sitaram Bhartia Institute of Science and Research
Indian Journal of Medical Research

Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies. Despite reservations about the utility, echocardiographic and Doppler (E&D) studies have identified a massive burden of RHD suggesting the inadequacy of the Jones' criteria updated by the American Heart Association in 1992. Subclinical carditis has been recognized by E&D in patients with acute RF without clinical carditis as well as by follow up of RHD patients presenting as isolated chorea or those without clinical evidence of carditis. Over the years, the medical management of RF has not changed. Paediatric and juvenile mitral stenosis (MS), upto the age of 12 and 20 yr respectively, severe enough to require operative treatement was documented. These negate the belief that patients of RHD become symptomatic ≥20 years after RF as well as the fact that congestive cardiac failure in childhood indicates active carditis and RF. Non-surgical balloon mitral valvotomy for MS has been initiated. Mitral and/or aortic valve replacement during active RF in patients not responding to medical treatment has been found to be life saving as well as confirming that congestive heart failure in acute RF is due to an acute haemodynamic overload. Pathogenesis as well as susceptibility to RF continue to be elusive. Prevention of RF morbidity depends on secondary prophylaxis which cannot reduce the burden of diseases. Primary prophylaxis is not feasible in the absence of a suitable vaccine. Attempts to design an antistreptococcal vaccine utilizing the M-protein has not succeeded in the last 40 years. Besides pathogenesis many other questions remain unanswered. Source

Sachdev H.P.S.,Sitaram Bhartia Institute of Science and Research
Indian Pediatrics

This policy review highlights the need to focus on stunting as an indicator of under-five undernutrition and explores the major challenges and priority public health options for accelerating linear growth in children. Early childhood stunting predicts poor human capital including shorter adult height, lower attained schooling, reduced adult income, and decreased offspring birth weight. The current prevalence of stunting is disconcerting but there has been a relatively faster decline recently. It is imperative to intervene before birth to address stunting. Pertinent ongoing interventions (delaying early child birth, adequate antenatal care and maternal iron-folate supplementation) are beneficial but have sub-optimal coverage. There is only a narrow window of opportunity in early life - the first two years. Effective coverage of children below two years of age with a package of interventions (breastfeeding; immunization; appropriate complementary feeding; treatment of infections, especially diarrhea; safe water supply; and sanitation) merits urgent investigation for greater impact. Source

Gogia S.,Max Hospital | Sachdev H.S.,Sitaram Bhartia Institute of Science and Research
International Journal of Epidemiology

Background: Maternal postpartum vitamin A supplementation (VAS) provides an opportunity to improve vitamin A nutriture of breast fed infants in developing countries and can possibly prevent infant mortality and morbidity attributable to vitamin A deficiency. Objective: To evaluate the effect of maternal postpartum VAS on infant mortality, morbidity and adverse effects. Design: Systematic review, meta-analysis and meta-regression of randomized controlled trials. Data sources: Electronic databases and abstracts and proceedings of micronutrient conferences. Review methods: Randomized or quasi-randomized, placebo-controlled trials evaluating the effect of postpartum, maternal synthetic VAS on mortality or morbidity within infancy (<1 year), or adverse effects. Results: The seven included trials were from developing countries. There was no evidence of a reduced risk of mortality during infancy [relative risk (RR) 1.05, 95% confidence interval (CI) 0.92-1.20, P = 0.438; I2 = 0%, P = 0.940]. No variable emerged as a significant predictor of mortality but data for high-risk groups (high maternal night blindness prevalence and low birth weights) was restricted. Neonatal mortality data was available from a single study, (RR 1.09, 95% CI 0.88-1.35; P = 0.422). In two trials, there was no evidence of a reduced risk of cause-specific mortality. In one trial, there was no evidence of a decrease in either diarrhoea or acute respiratory infection. No adverse effects were reported in the single relevant trial. Conclusions: There is no evidence of a mortality or morbidity benefit to the infant following postpartum maternal VAS. Only prevention of infant morbidity or mortality would be sufficient justification for initiating this intervention in public health programmes. Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2010; all rights reserved. Source

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