Swaddling Practices in an Indian Institution: Are they Hip-Safe? A Survey of Paediatricians,Nurses and Caregivers

PurposeTraditional infant swaddling or binding with hips and knees extended is a known risk factor for Developmental Dysplasia of the Hip (DDH), while ‘hip-safe swaddling’ with hips and knees flexed is believed to eliminate this risk. We conducted a survey to determine the prevalent practices for infant swaddling in India; why mothers practice swaddling and who teaches them; and whether Paediatricians, nurses and caregivers are aware of hip-safe swaddling.MethodsAnonymous one-time surveys were conducted in three groups–Paediatricians, Nurses and caregivers – at a tertiary-care, urban based, paediatric and maternity hospital.ResultsForty-five paediatricians, 219 nurses and 100 caregivers were surveyed. Ninety percent caregivers practiced traditional swaddling, for on average 10.2 hours a day, starting soon after birth, up to 4.2 months of life. Traditional swaddling was advocated by 99% nurses and 53% Paediatricians. Reasons for swaddling included sleep, warmth and the misbelief that the child’s legs would remain bowed if not bound straight; contrarily few mothers (8%) avoided swaddling out of superstition. Mothers learnt swaddling mainly from relatives (94%) and nurses (64%). Most nurses (70%) had learnt the practice during nursing training. Only 6.6% Paediatricians, 4% caregivers and 0% nurses were aware of ‘hip-safe swaddling’.ConclusionTraditional swaddling of infants is a practice deeply rooted in India, born out of misbeliefs, and propagated by lack of awareness. Training in hip-safe swaddling targeted at nurses and Paediatricians would be an effective initial step in creating awareness among mothers and changing their practices.Electronic supplementary materialThe online version of this article (10.1007/s43465-020-00188-2) contains supplementary material, which is available to authorized users.     

Glial-released proteins in clonal cultures and their modulation by hydrocortisone

Rat glial C6 cells release into the culture medium a reproducible spectrum of soluble proteins of 12 major peaks over a broad molecular weight range as determined by fractionation on SDS-gel electrophoresis. Exposing C6 monolayers to hydrocortisone (HC) results in a selective alteration in the pattern of glial-released protein (GRP). The selective HC-induced increase or decrease in GRP peaks is specific to HC in that 17β-estradiol, dibutyryl cyclic AMP, isoproterenol and melatonin exert either no detectable or a qualitatively different influence on the GRP pattern. The HC influence is dose dependent over a physiological range of concentrations from 10⁻⁹ to 10⁻⁶ M. Differences in culture age and in subclones of C6 can influence both the normal and the HC-induced pattern of GRP. The origin of the GRO is unknown, but pattern reproducibility, viability tests, surface labeling studies and metabolic labeling studies of soluble and particulate compartment proteins and glycoproteins support the position that cell lysis is not an important source of GRP. More importantly, these studies indicate that GRP and HC-induced changes in GRP pattern are physiologically significant aspects of glial cell behavior.     

Epiphyseal separations in spastic cerebral palsy

Metaphyseal and diaphyseal fractures have been reported in children with severe spastic cerebral palsy, but there is no reference to epiphyseal separations in these patients. We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely affected children with spastic quadriplegic cerebral palsy. The clinico-radiological features confirmed the cause to be scurvy. These epiphyseal separations have a good prognosis unlike the physeal injuries reported in children with myelodysplasia. Treatment with vitamin C and splintage resulted in rapid healing with excellent remodeling. Scurvy should be considered a potential cause for an epiphyseal slip in a child with severe spastic cerebral palsy. Routine dietary supplementation of vitamin C is recommended for these malnourished and nonambulant children.     

Glial-released proteins: III. Influence on neuronal morphological differentiation

The proteins released into the culture medium (CM) by confluent C6 glioma cell monolayers were analyzed by two-dimensional sodium dodecyl sulfate polyacrylamide gel electrophoresis (2-D SDS-PAGE). These cells synthesize and release a complex set of proteins which can be resolved on the basis of molecular charge and size. Over 400 spots on fluorograms corresponding to radio-labeled glial-released protein (GRP) were detected and classified according to their positions in 2-D gels. The marked species charge heterogeneity of the 2-D pattern was used as a criterion to assign the majority of GRP components to ‘series’. Series are composed of families of related proteins or glycoproteins distributed in a line of evenly spaced members in the isoelectric focusing dimension. Long-term exposure of monolayers to 2 μM hydrocortisone influenced the accumulation in the culture medium of half of the classified GRP species. Five classes of GRP were identified based on their steroid-responsiveness as seen in the deviation of GRP radiolabel ratios from control and hormone-treated culture CM. Hormonal response, verified by reverse-label experiments, showed a number of GRP in CM are either consistently increased 1-to-fold (Classes I and II) or decreased 1-to 3-fold (Classes IV and V). The remaining GRP (Class III) included those proteins which were found to be uninfluenced or to change in a weak or inconsistent manner. Some GRP series were coordinately induced while other series gave graded responses. These results represent the first high-resolution classification of GRP by physical and biological properties.     

Irreducible lateral dislocation of the elbow

A rare case of an irreducible post-traumatic lateral dislocation of elbow is presented. The mechanism of injury was fall on a flexed elbow with trauma on its medial aspect resulting in pronation of the forearm. At open reduction, the brachialis muscle was in the form of a tight band which prevented reduction. The ulnar nerve was entrapped in the joint.     

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions

PurposeIn India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country’s needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.MethodsIn Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway.ResultsThe Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country’s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.Discussion/ConclusionIn Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways.Level of EvidenceLevel III.     

Initial experiences of cataract & lens surgery in 1269 patients in outpatient clean rooms using a portable laminar air flow device

BackgroundIn 2020, routine cataract surgery was halted in most countries due to the COVID-19 pandemic in order to reduce transmission. With a consequent lack of theatre space, we developed a safe cataract pathway in outpatient department clean rooms to minimize patient exposure and time spent in hospital using a sterile laminar air flow device. We describe our initial experiences of restarting elective cataract surgery in the UK outpatient setting, outside of the operating theatre environment.MethodsThis was a prospective consecutive study of our clinical practice. A sterile air zone unit, the Toul Meditech Operio Mobile device, was used to create a sterile surgical site in three separate outpatient clean rooms from May 2020 to December 2021 in different geographical locations within Herefordshire, UK. Observations of the time spent in the department and a formal patient satisfaction survey were carried out for the initial 100 patients. All patients were followed up to assess development of post-operative complications.Results1269 patients were included in the study. No patients sustained post-operative infection (n = 0/1269, 0%). For the initial 100 patients, the average time spent within the department was 74.3 min (unilateral cases, range 45–115 min) and 93.1 min (bilateral, 55–135 min). Patient satisfaction was high.ConclusionInitial results demonstrate a safe, efficient and effective cataract surgery pathway with high patient satisfaction by converting outpatient clean rooms into ophthalmic operating theatres using the Toul Meditech Operio Mobile.Subject terms: Surgery, Technology     

Convergent radioulnar translocation with radial head fracture in a child: a case report and review of the literature

SUMMARY: Convergent type radioulnar translocation is an extremely rare form of injury occurring in a growing child. We report a case of convergent radioulnar translocation along with a radial head fracture in a young child. Open reduction of the elbow and internal fixation of the radial head fragment helped in achieving concentric reduction and good functional outcome at 2 years of follow-up. This case has been shown to highlight the diagnostic and management issues of this rare condition, which may be easily missed initially.     

The discovery of orally active triaminotriazine aniline amides as inhibitors of p38 MAP kinase

A new structural class of triaminotriazine aniline amides possessing potent p38 enzyme activity has been discovered. The initial hit (compound 1a) was identified through screening the Pharmacopeia ECLiPS compound collection. SAR modification led to the identification of a short acting triaminotriazine aniline methoxyamide (compound 1m) possessing in vitro and in vivo oral activity in animal models of acute and chronic inflammatory disease. An X-ray crystal structure of compound 1m in this class, cocrystallized with unactivated p38 alpha protein, indicates that these compounds bind to the ATP binding pocket and possess key H-bonding interactions within a deeper cleft. Hydrogen bonding between one of the triazine nitrogens and the backbone NH of the Met109 residue occurs through a water molecule. The methoxyamide NH and carbonyl oxygen are within H-bonding distance of Glu71 and Asp168.