The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries

BACKGROUND

Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries.

METHODS

WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women.

DISCUSSION

This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally.

TRIAL REGISTRATION

ISRCTN11434567 . Registered on 7 June 2021.

Clinical Correlation of Vitamin D Deficiency and Early Childhood Caries: A Cross-Sectional Study in Western Rajasthan

Objectives

To ascertain whether a link exists between vitamin D insufficiency and early childhood caries or not.

Method

From the out patient department (OPD) of the Pedodontics Department at Vyas Dental College, a random sample of 40 kids between the ages of 8 months and 5 years old was chosen. Each kid had blood drawn to check their serum 25(OH) vitamin D levels. All of the data was collated and given the necessary statistical analysis.

Result

The case group's mean serum 25(OH) vitamin D level was 10.19 ng/mL (with a standard deviation of 3.46), while the control group's was 20.84 ng/mL (2.54 SD).

Conclusion

A significant modifiable risk factor for childhood dental caries is a vitamin D deficiency. Therefore, cavities in teeth can be avoided by giving youngsters vitamin D supplements and avoiding vitamin D insufficiency.

Clinical Efficacy of Topical Kenacort and Aloe Vera Gel in Minor Aphthous Stomatitis: A Comparative Study

Aim

The aim of the study is to compare the clinical efficacy of both the topical agents-aloe vera gel and Kenacort oral paste (0.1% triamcinolone acetonide) in patients with minor aphthous stomatitis.

Materials and Methods

60 patients were recruited for the study and were randomly divided into two groups-Group A (aloe vera gel group) and Group B (Kenacort oral paste group). The baseline parameters were taken and recorded on the day of the first visit which included ulcer size, pain, and burning sensation. Evaluation of reduction in ulcer size, pain, and burning sensation were made on day 3 and day 7.

Results

The results of the present study revealed that both the study groups showed no significant difference in the size of ulcer at day 1, day 3, and day 7 when compared using independent t-test as P > 0.05 at all study intervals. Therefore, both the agents were found to be equally effective against reducing the size of ulcer, pain, and burning sensation.

Conclusion

The present study findings demonstrate that topical application of the aloe vera gel was able to decrease the ulcer size, intensity of pain, and burning sensation, thereby accelerating the healing without any side effects. Thus, topical aloe vera could be safe and a better alternative to topical steroid for RAS.

Comparative Evaluation of Sealing Ability of Three Different Materials as Barriers to Coronal Microleakage in Root-Filled Teeth: An In Vitro Study

Aim

To compare the sealing ability of three different materials when used as postendodontic restoration barriers to coronal microleakage in root-filled teeth.

Materials and Methods

In the present study, 60 single-rooted mandibular premolars with single canals were selected. After endodontic treatment was done with protaper files, they were divided into three groups of 20 teeth each, which were restored with Zirconomer (Group I), Hi-Dense (Group II), and Surefil composite (Group III), respectively. After storing in artificial saliva for 10 days, all teeth were then immersed in Rhodamine 6G fluorescent dye. Teeth were then sectioned buccolingually in a longitudinal direction. The coronal microleakage was measured in both halves under a fluorescence microscope and images were taken with a digital camera. Data obtained from the study in the form of scoring as per specific criteria was subjected to statistical analysis.

Result

Results of the study showed that the minimum amount of coronal microleakage was seen in Group II restored with Hi-Dense followed by Group III restored with Surefil Composite and the maximum amount of coronal microleakage was seen in Group I restored with Zirconomer.

Conclusion

On the basis of the results of the present study, it may be concluded that Hi-Dense showed better coronal sealing ability in access cavities. Surefil composite exhibited coronal microleakage less than Zirconomer but more than Hi-Dense.

Unveiling Mysteries of Quid-Induced Lichenoid Reactions: A Cross-Sectional Study

Lichenoid reactions occur exclusively in people who chew tobacco, areca nut, or both, in raw or any manufactured or processed form. The lesion is described as a lichen-planus-like lesion and is termed as quid-induced lichenoid reaction (QILR). In this cross-sectional study, amongst 935 quid consumers, 82 patients were diagnosed with QILR and it was seen that 65 patients used processed forms of tobacco and areca nut. Thereby, it could be concluded that QILR might occur because of flavors used in processing of tobacco and areca nut.

Procalcitonin for Detecting Culture-Positive Sepsis in Neonates: A Prospective, Multicenter Study

INTRODUCTION

It is unclear if serum procalcitonin (PCT) estimated at sepsis suspicion can help detect culture-positive sepsis in neonates. We evaluated the diagnostic performance of PCT in culture-positive sepsis in neonates.

METHODS

This was a prospective study (February 2016 to September 2020) conducted in four level-3 units in India. We enrolled neonates suspected of sepsis in the first 28 days of life. Neonates with birth weight <750 g, asphyxia, shock, and major malformations were excluded. Blood for PCT assay was drawn along with the blood culture at the time of suspicion of sepsis and before antibiotic initiation. The investigators labeled the neonates as having culture-positive sepsis or "no sepsis" based on the culture reports and clinical course. PCT assay was performed by electrochemiluminescence immunoassay, and the clinicians were masked to the PCT levels while assigning the label of sepsis. Primary outcomes were the sensitivity, specificity, and likelihood ratios to identify culture-positive sepsis.

RESULTS

The mean birth weight (SD) and median gestation (IQR) were 2,113 (727) g and 36 (32-38) weeks, respectively. Of the 1,204 neonates with eligible cultures, 155 (12.9%) had culture-positive sepsis. Most (79.4%) were culture-positive within 72 h of birth. The sensitivity, specificity, and positive and negative likelihood ratios at 2 ng/mL PCT threshold were 52.3% (95% confidence interval: 44.1-60.3), 64.5% (60.7-68.1), 1.47 (1.23-1.76), and 0.74 (0.62-0.88), respectively. Adding PCT to assessing neonates with 12.9% pretest probability of sepsis generated posttest probabilities of 18% and 10% for positive and negative test results, respectively.

CONCLUSION

Serum PCT did not reliably identify culture-positive sepsis in neonates.

Effect on neonatal sepsis following immediate kangaroo mother care in a newborn intensive care unit: a post-hoc analysis of a multicentre, open-label, randomised controlled trial

Background

To implement the immediate Kangaroo mother care (iKMC) intervention in the previous multicentre, open-label, randomised controlled trial, the mother or a surrogate caregiver and neonate needed to be together continuously, which led to the concept of the Mother-Newborn Care Unit (MNCU). Health-care providers and administrators were concerned of the potential increase in infections caused by the continuous presence of mothers or surrogates in the MNCU. We aimed to assess the incidence of neonatal sepsis in sub-groups and the bacterial profile among intervention and control neonates in the study population.

Methods

This is a post-hoc analysis of the previous iKMC trial, which was conducted in five level 2 Newborn Intensive Care Units (NICUs) one each in Ghana, India, Malawi, Nigeria, and Tanzania, in neonates with birth weight 1 to <1.8 kg. The intervention was KMC initiated immediately after birth and continued until discharge and compared to conventional care with KMC initiated after meeting stability criteria. The primary outcomes of this report were the incidence of neonatal sepsis in sub-groups, sepsis-related mortality and bacterial profile of isolates during hospital stay. The original trial is registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12618001880235) and the Clinical Trials Registry-India (CTRI/2018/08/01536).

Findings

Between November 30, 2017, and January 20, 2020, 1609 newborns in the intervention group and in the control group 1602 newborns were enrolled in iKMC study. 1575 newborns in the intervention group and 1561 in the control group were clinically evaluated for sepsis. Suspected sepsis was 14% lower in intervention group in sub-group of neonates with birth weight 1.0-<1.5 kg; RR 0.86 (CI 0.75, 0.99). Among neonates with birth weight 1.5-<1.8 kg, suspected sepsis was reduced by 24%; RR 0.76 (CI 0.62, 0.93). Suspected sepsis rates were lower in intervention group than in the control group across all sites. Sepsis related mortality was 37% less in intervention group than the control group; RR 0.63 (CI 0.47-0.85) which was statistically significant. The intervention group had fewer cases of Gram-negative isolates (n = 9) than Gram positive isolates (n = 16). The control group had more cases of Gram-negative isolates (n = 18) than Gram positive (n = 12).

Interpretation

Immediate Kangaroo Mother care is an effective intervention to prevent neonatal sepsis and sepsis related mortality.

Funding

The original trial was funded by the Bill and Melinda Gates Foundation through a grant to the World Health Organization (grant No. OPP1151718).

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Immediate skin-to-skin contact for low birth weight infants is safe in terms of cardiorespiratory stability in limited-resource settings

Aim

To investigate the safety of skin-to-skin contact initiated immediately after birth on cardiorespiratory parameters in unstable low birth weight infants.

Methods

A randomized clinical trial was conducted in tertiary newborn units in Ghana, India, Malawi, Nigeria and Tanzania in 2017-2020, in infants with birth weight 1.0-1.799 kg. The intervention was Kangaroo mother care initiated immediately after birth and continued until discharge compared to conventional care with Kangaroo mother care initiated after meeting stability criteria. The results of the primary study showed that immediate Kangaroo mother care reduced neonatal mortality by 25% and the results have been published previously. The post-hoc outcomes of this study were mean heart rate, respiratory rate, oxygen saturation during the first four days and the need of respiratory support.

Results

1,602 infants were allocated to control and 1,609 to intervention. Mean birth weight was 1.5 kg (SD 0.2) and mean gestational age was 32.6 weeks (SD 2.9). Infants in the control group had a mean heart rate 1.4 beats per minute higher (95% CI -0.3-3.1, p = 0.097), a mean respiratory rate 0.4 breaths per minute higher (-0.7-1.5, p = 0.48) and a mean oxygen saturation 0.3% higher (95% CI -0.1-0.7, p = 0.14) than infants in the intervention group.

Conclusion

There were no significant differences in cardiorespiratory parameters during the first four postnatal days. Skin-to-skin contact starting immediately after birth is safe in low birth weight infants in limited-resource settings.

Uniportal video-assisted thoracoscopic surgery in semi-prone position utilising direct endobronchial intubation for oesophagus leiomyoma excision

Leiomyomas are the most common benign tumours of oesophageal smooth muscle origin. In this era of constantly evolving medical technology, video-assisted, robot-assisted and endoscopic approaches are the minimally invasive strategies for the excision of these lesions. Here, we report our modification of this surgery. The lesion was excised with uniportal video-assisted thoracoscopic surgery in a semi-prone position with single-lumen endobronchial intubation.

Management of Cylindrical Battery Ingestion

Presentation A female presented to the Emergency Department following ingestion of an unknown number of cylindrical batteries. Diagnosis Abdominal X-ray confirmed the presence of multiple batteries located throughout the abdomen. Treatment A trial of conservative management was pursued, and five AA batteries were successfully passed per rectum. Serial X-rays over three weeks revealed that the majority of batteries failed to pass. A decision was made to perform a laparotomy, and 46 cylindrical batteries were removed from the stomach through a small gastrotomy. Four batteries located in the colon were milked into the rectum and removed via the transanal route. Discussion Using daily clinical exams and weekly plain films of the abdomen, conservative management is possible if a small number of batteries are ingested and make it to the stomach. However, the potential of cylindrical batteries to result in acute surgical emergencies should not be underestimated.

Trivialization of Aggression Against Women in India: An Exploration of Life Writings and Societal Perception

Purpose

Aggression, or an action that intend to harm, encompasses different forms with varying intensity, impact, and salient features. Globally and in Indian context specifically, aggression against women is often normalized if there is no physical aggression involved as the hurt caused tends to be invisible. The current study explored the perceived intensity of physical, verbal, and sexual aggression among south Indian adults.

Method

Aggressive instances from the life writings of two south Indian women were chosen and were rated by five independent coders to check inter-coder reliability. The select narratives disclose instances of domestic aggression. Ten instances with highest ratings were chosen as the material for data collection. Adults (N = 145) from two southern states had reported the perceived intensity of aggression in each context. Textual analysis and ANOVA were the analytic techniques adopted.

Results

The results indicate trivialization of verbal aggression compared to physical and sexual aggression. Further, the instances of verbal or more subtle aggression were perceived as even more trivial when the respondents got exposed to the instances of explicit physical and sexual aggressions first.

Conclusions

The findings indicate trivialization of verbal and implicit forms of aggression, particularly when exposed along with physical and explicit forms of aggression. Consequences of different forms of aggression were not considered significant by the respondents. Suggestions for further studies, changes in policy-making, and law-enforcement were made based on the current results.

Effect of type 1 tympanoplasty on the quality of life of patients suffering from chronic otitis media (safe type)

Background

Chronic otitis media (COM) remains a major public health issue and is associated with relentless discharge from the ear, pain, significant functional limitation of hearing, leading to communication problems and frequent specialist visits.

Aims

To assess the improvement in quality of life of patients of COM (safe type) and surgical success in terms of graft uptake and improvement in hearing.

Patients and Methods

A prospective questionnaire-based outcome study was directed in 100 patients with COM who were treated with Type I Tympanoplasty at our institution between May 2018 and May 2020. All patients were asked to fill Modified Chronic Otitis Media 4 (COM-4) survey before operation and 3 months after operation. Preoperative and postoperative total ear scores, audiological results, postoperative graft uptake were assessed.

Results

The correlation between preoperative and postoperative assessment by questionnaire was statistically critical (P < 0.001). There was significant improvement in hearing postoperatively (P < 0.001). Effective graft uptake was seen in 80%.

Conclusion

The current study emphasizes that Type 1 Tympanoplasty fundamentally improves quality of life of patients in terms of physical suffering, hearing loss, emotional distress postoperatively.

Family violence during COVID-19 and its impact on mental health of children: A systematic review

Purpose: The COVID-19 pandemic posed unanticipated challenges that could impact how the family system operates across the world. Restrictions imposed to control the rapid spread of the virus substantially increased violence in families. The current study aims to review violence in the family and its impact on the mental health of children during the pandemic.Method: A systematic search was conducted using keywords in the electronic databases PubMed, PsycINFO, and Web of Science, and a manual search was conducted on Google Scholar for articles from January 2020 to January 2021. Of the 50 records identified, seven studies that met eligibility criteria were selected for final analysis.Results: Results revealed that family violence during the pandemic has escalated the mental health problems of children, including aggressive and self-harming behaviours. Lockdown restrictions, social detachment, financial instability, fear of infection, and unemployment led to increased parental stress. Parents with a higher level of stress were more likely to maltreat their children.Conclusions: Exposure to short and long-term family violence can adversely impact the mental health of children and can negatively affect a child's present and future life. Recommendations for researchers, mental health practitioners, public health authorities, and other service providers are also outlined.

Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight

BACKGROUND

"Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

METHODS

We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

RESULTS

A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

CONCLUSIONS

Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).

Bacterial Colonization of Vagina in Indian Women During Labor and Its Association With Puerperal and Neonatal Sepsis: A Tertiary Hospital Study

Objective

The aim was to find the prevalence of colonization of vagina with aerobic bacteria among low-risk Indian women in active labor and its association with early-onset neonatal sepsis (EONS) and puerperal sepsis.

Methods

The study was conducted prospectively from October 2018 to March 2020 in a tertiary hospital in New Delhi, India. Low-risk pregnant women (N=920) in active labor with intact membranes were recruited. High vaginal swabs were collected, cultured by standard methods to detect aerobic bacteria. The primary outcomes were the development of puerperal sepsis and EONS.

Results

In a total of 920 low-risk subjects, vaginal colonization was found in 484 (52.6%), coagulase-negative Staphylococcus being the predominant colonizer (13.2%) followed by Escherichia coli (8.9%). Multigravida women were at 1.4 times higher risk of colonization than primigravida (odds ratio [OR] 1.399; 95% CI 1.064, 1.84). Women whose sample was collected at the first vaginal examination were at 0.34 times lower risk of colonization as compared to women with more than one vaginal examination (OR 0.34; 95% CI 0.241, 0.481). The incidence of colonization increased with progressive vaginal examinations (p<0.001). None of the colonized women and their neonates developed puerperal sepsis or EONS, respectively.

Conclusion

Vaginal colonization of aerobic bacteria in active labor is not associated with an increased risk of puerperal sepsis or EONS.

Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers' voices and experiences

INTRODUCTION

The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies.

METHODS

Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.

RESULTS

We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%).

CONCLUSION

Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Health risks associated with fluoride intake from rural drinking water supply and inverse mass balance modeling to decipher hydrogeochemical processes in Vattamalaikarai River basin, South India

Preliminary investigation reveals that fluorosis is reported due to the continuous intake of fluoride-rich groundwater in Vattamalikarai River basin, Tamil Nadu, India. A detailed study was attempted for evaluating the health risks associated with the intake of fluoride-rich groundwater supplied to the rural community. Groundwater samples were collected from 60 and 58 dug and tube wells during winter and southwest (SW) monsoon seasons respectively. The samples were analyzed for the determination of fluoride and other chemical parameters to examine the fitness for drinking water. Spatio-temporal variation maps reveal that fluoride concentration is high during SW monsoon season when compared with the winter season in this region. The fluoride bearing minerals present in hornblende-biotite gneiss and charnockite rock formations leached into the groundwater during rock-water interaction. To understand the subsurface hydrogeochemical reactions, inverse mass balance model was developed using NETPATH code. The model output indicates that calcite dilution, silicate (hornblende and biotite) weathering, ion exchange (Ca/Na and Mg/Na) and illite precipitation are the dominant processes controlling the groundwater chemistry along the flow paths. Non-carcinogenic risks to children and adults (women and men) were evaluated by working out intake exposure of groundwater. Hazard quotient (HQ) based on fluoride intake was calculated for children and adults. It varied from 0.08 to 2.21 with an average of 1.07 for adults. For children, it varied from 0.01 to 2.99 with the mean of 1.44. About 78%, 69% and 61% of the samples fall under the risk category for children, women and men during winter season. However, more number of samples possessed health risks (83% of samples for children, 73% of samples for women and 64% of samples for men) during SW monsoon season.

Neonatal Chikungunya: A case series

Chikungunya virus is an RNA virus that belongs to the family Togaviridae, genus Alphavirus, transmitted by Aedes mosquitoes. The disease usually manifests as fever, arthralgia and petechial or maculopapular rash. The illness is usually self-limiting. We report a series of neonates infected with Chikungunya virus, confirmed by ELISA test, showing that viral Chikungunya can be transmitted from mother to babies and its clinical presentation is that of septicemia or meningitis.

Metabolic Syndrome in Patients with Bipolar Disorder Treated with Atypical Antipsychotics, their First-degree Relatives and Control Group

Introduction and objective

Patients with serious mental illness have lower life expectancy and higher prevalence of metabolic syndrome compared to normal population. Although, we have little evidence about their first-degree relatives.

Aims

To compare metabolic syndrome in patients with bipolar disorder treated with atypical antipsychotics, their first degree relatives and healthy subjects in two age groups: under and over 40.

Methods

This cross-sectional study was conducted on 100 patients with bipolar disorder treated with atypical antipsychotics, 50 first degree relatives and 135 healthy subjects. The prevalence of metabolic syndrome was assessed based on National Cholesterol Education Program (NCEP).

Results

Under the age of 40, the prevalence of metabolic syndrome was 15.4% in patients with Bipolar disorder, 17.6% in first degree relatives and 7% in healthy subjects. Systolic blood pressure was significantly higher in bipolar disorder patients (P = 0.004). In those over 40, the prevalence of metabolic syndrome was 31.8% in patients with bipolar disorder, 33.3% in first-degree relatives and 32.8% in healthy subjects. Serum levels of HDL were significantly lower in bipolar disorder patients (P = 0.002).

Conclusion

Patients with bipolar disorder and their first-degree relatives have greater chance for cardiovascular disease due to higher metabolic syndrome. Further investigations are needed for evaluating serious mental illness patients and their relatives.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital

Background:

Septicemia is an important cause of neonatal morbidity and mortality. However, organized data on causative organisms and their resistant pattern are scanty from developing countries. The changing trend in causative organisms and their antibiotic resistance is yet to be documented in India. The present study examines the trends in bacterial profile and antibiotic resistance of the organisms causing sepsis in hospitalized neonates.

Materials and Methods:

A retrospective laboratory-based analysis of blood cultures obtained from Neonatal Intensive Care Unit of a tertiary care hospital in New Delhi was done for the period of 1999–2014, divided into five phases.

Results:

A total of 4700 isolates were considered. Over time, Gram-negative organisms have replaced Gram-positives as frequent isolates. Initially, there was predominance of Klebsiella pneumoniae, then of Staphylococcus aureus which recently has been changed with coagulase negative-Staphylococcus and Acinetobacter. Growing resistance against the first and second line of drugs has been noted, including methicillin-resistant S. aureus and vancomycin-resistant Enterococcus.

Conclusion:

The etiological profile of neonatal sepsis has changed tremendously in the past 15 years. High resistance against common drugs necessitates continued surveillance and review of empirical antibiotic policy for neonatal sepsis. These steps are important to effectively curtail the surge of further antibiotic resistance.

Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

OBJECTIVE

To develop and assess Pediatric Appropriateness Evaluation Protocol for India (PAEP-India) for inter-rater reliability and appropriateness of hospitalization.

DESIGN

Cross-sectional study.

SETTING

The available PAEP tools were reviewed and adapted for Indian context by ten experienced pediatricians following semi-Delphi process. Two PAEP-India tools; newborn (≤28 days) and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness of admission and inter-rater reliability between assessors.

PARTICIPANTS

Two sets of case records were used: (i) 274 cases from five medical colleges in Delhi-NCR [≤28 days (n=51); >28 days to 18 years (n=223)]; (ii) 622 infants who were hospitalized in 146 health facilities and were part of a cohort (n= 30688) from two southern Indian states.

INTERVENTIONS

Each case-record was evaluated by two pediatricians in a blinded manner using the appropriate PAEP-India tools, and 'admission criteria' were categorized as appropriate, inappropriate or indeterminate.

OUTCOME MEASURES

The proportion of appropriate hospitalizations and inter-rater reliability between assessors (using kappa statistic) were estimated for the cases.

RESULTS

97.8% hospitalized cases from medical colleges were labelled as appropriate by both reviewers with inter-rater agreement of 98.9% (k=0.66). In the southerm Indian set of infants, both reviewers labelled 80.5% admissions as appropriate with inter-rater agreement of 96.1% (k= 0.89).

CONCLUSIONS

PAEP-India (newborn and child) tools are simple, objective and applicable in diverse settings and highly reliable. These tools can potentially be used for deciding admission appropriateness and hospital stay and may be evaluated later for usefulness for cost reimbursements for insurance proposes.

Mother-Neonatal Intensive Care Unit (M-NICU): A Novel Concept in Newborn Care

Health facilities in India are faced with the challenge of providing quality newborn care in the face of major skilled human resource shortage. A possible solution is the concept of Mother-Neonatal ICU (M-NICU), where the mother has her bed inside the neonatal intensive care unit (NICU) by the side of baby's warmer. Our observations in M-NICU of a public sector hospital in New Delhi, India, indicate that mothers can be easily trained to follow asepsis routines and monitor the neonates, and are better prepared for their post-discharge care. Incorporating space for both mothers and their newborns in level-II NICUs may provide quality and developmentally supportive newborn care in coming years.

Adult Bochdalek Hernia with Organo-Axial Gastric Volvulus: Misdiagnosed as Hydropneumothorax

Bochdalek hernia (BH) in an adult may manifest clinically with a myriad of abdominal or chest symptoms or a combination of them. Diagnosis of an adult BH is usually delayed in view of rarity of the lesion and its varied presentation. A 30-year-old adult gentleman presented to us with a left thoracostomy which was draining pus and ingested food particles. The tube thoracostomy had been performed in another hospital for an apparent left hydropneumothorax before he arrived in our hospital. Computed tomography of Chest and abdomen revealed a left diaphragmatic defect with herniation of stomach, spleen and omentum into the chest with organo-axial volvulus of the stomach. A thoracostomy tube was seen to be traversing through the stomach with its tip located close to the left pulmonary artery. The patient underwent left thoraco-abdominal exploration with dissection and reposition of the hernial contents in the abdominal cavity. The gastric perforations and the diaphragmatic defect were repaired. This case reiterates a well-known fact that an adult type BH must find a place in the differential diagnosis of a hydropneumothorax. Though the adult BH is a rare diagnosis, unawareness or reluctance to consider the possibility of adult BH may prolong the suffering of the patient as it happened in our patient who had iatrogenic perforation of the stomach due to tube thoracostomy.

Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study

AIM

Involvement of the anterior mesorectal fascia (iAMRF) after neoadjuvant treatment leads to either resection of the involved organ alone [extended resection of the rectum (ERR)] or total pelvic exenteration (TPE). The purpose of this study was to compare the rate of recurrence and survival of patients undergoing ERR or TPE for iAMRF after neoadjuvant treatment. The outcome of patients who underwent total mesorectal excision after downstaging was also compared.

METHOD

This was a retrospective study of primary rectal cancer patients.

RESULTS

Of 237 patients, 61 (21.5%) patients with nonmetastatic carcinoma rectum had iAMRF at baseline. Ten patients defaulted before completion of neoadjuvant chemoradiotherapy. After neoadjuvant chemoradiotherapy, 22 patients (43.1%) developed systemic metastases, seven patients (13.8%) were downstaged to free anterior mesorectal fascia and underwent total mesorectal excision (anterior resection/abdominoperineal resection) and the remaining 22 patients (43.1%) had persistent iAMRF. Thirteen patients with persistent iAMRF underwent ERR, whereas nine patients underwent TPE. The median duration of hospital stay in the TPE group was 13 days (10-26), whereas it was 7 days (5-21) in the ERR group. A clear circumferential resection margin, R0 resection, was achieved in all patients with TPE and ERR. After a median follow-up of 31.6 months, five patients with TPE (55.6%), four patients with ERR (30.7%) and three patients in the downstaged group (42.9%) developed systemic recurrence. None of the patients with TPE and the downstaged group developed local recurrence, whereas three patients with ERR (23.1%) developed local recurrence. Median disease-free survival was 12.3 months in the TPE group, 18.9 months in the ERR group and 10.6 months in the downstaged group, whereas mean overall survival was 36.2, 32.8 and 27.9 months, respectively.

CONCLUSION

Although there is no significant difference in the overall survival and disease-free survival, ERR is associated with a high risk of local recurrence compared to TPE and the downstaged group.

Alarming rates of antimicrobial resistance and fungal sepsis in outborn neonates in North India

BACKGROUND

There is a paucity of data on the epidemiology of sepsis in outborn neonates being referred to level-3 units in low- and middle-income countries (LMIC). The objective of the present study was to evaluate the prevalence of sepsis and outcomes of outborn neonates with sepsis, and to characterize the pathogen profile and antimicrobial resistance (AMR) patterns of common isolates in them.

METHODS

In this prospective observational cohort study (2011-2015), a dedicated research team enrolled all neonates admitted to an outborn level-3 neonatal unit and followed them until discharge/death. Sepsis work-up including blood culture(s) was performed upon suspicion of sepsis. All the isolates were identified and tested for antimicrobial susceptibility. Gram-negative pathogens resistant to any three of the five antibiotic classes (extended-spectrum cephalosporins, carbapenems, aminoglycosides, fluoroquinolones, and piperacillin-tazobactam) were labeled multi-drug resistant.

RESULTS

Of the total of 2588 neonates enrolled, culture positive sepsis and total sepsis-i.e. culture positive and/or culture negative sepsis-was diagnosed in 13.1% (95% CI 11.8% to 14.5%) and 54.7% (95% CI 52.8% to 56.6%), respectively. The case fatality rates were 23.4% and 11.0% in culture-positive and total sepsis, respectively. Sepsis accounted for two-thirds of total neonatal deaths (153/235, 63.0%). Bacterial isolates caused about three-fourths (296/401; 73.8%) of the infections. The two common pathogens-Klebsiella pneumoniae (n = 50, 12.5%) and Acinetobacter baumannii (n = 46, 11.5%)-showed high degree of multi-drug resistance (78.0% and 91.3%, respectively) and carbapenem resistance (84.0% and 91.3%, respectively). About a quarter of infections were caused by Candida spp. (n = 91; 22.7%); almost three-fourths (73.7%) of these infections occurred in neonates born at or after 32 weeks' gestation and about two-thirds (62.1%) in those weighing 1500 g or more at birth.

CONCLUSIONS

In this large outborn cohort, we report high burden of sepsis, high prevalence of systemic fungal infections, and alarming rates of antimicrobial resistance among bacterial pathogens.

Acute Kidney Injury in Neonatal Sepsis: Risk Factors, Clinical Profile, and Outcome

Objective This study aims to determine the proportion of cases of neonatal sepsis developing acute kidney injury (AKI).

Methods This is a prospective observational study conducted in the nursery of a tertiary care center in Northern India during October 2012 to March 2014. Newborns with symptoms suggestive of sepsis were investigated. Those with congenital renal anomalies and negative for sepsis were excluded from the study. Newborns with sepsis were treated accordingly and observed for AKI until discharge or death. Acute Kidney Injury Network definition was used to define AKI in this study.

Results A total of 310 neonates with sepsis were enrolled out of which 3.87% neonates developed AKI. Factors such as maternal age, sex, birth weight, gestational age, asphyxia, the risk factor of sepsis in the mother, meconium-stained liquor, and mode of delivery were not found to be associated with AKI. Meningitis (p < 0.05) was found to be significantly associated with AKI. Duration of stay was longer for those with AKI (p < 0.01), but the mortality rate did not differ significantly among those with AKI and those without AKI. Around 25% of cases were found to be AKI stage 1, 25% of cases were AKI stage 2, and 50% of cases were AKI stage 3.

Conclusion It is difficult to predict AKI based on clinical features, so it is better to screen all the neonates with sepsis for AKI so that they can be managed accordingly, as AKI detected early has a better prognosis.

Healthcare associated infections in neonatal intensive care unit and its correlation with environmental surveillance

Healthcare-associated infections (HAI) are frequent complications in neonatal intensive care units (NICU) with varying risk factors and bacteriological profile. There is paucity of literature comparing the bacteriological profile of organisms causing HAI with the environmental surveillance isolates. Therefore, this study aimed to evaluate demographic profile, risk factors and outcome of HAI in NICU and correlate with environmental surveillance. Three hundred newborns with signs and symptoms of sepsis were enrolled in the study group and their profile, risk factors and outcome were compared with the control group. Univariate analysis and multivariable logistic regression were performed. Environmental surveillance results were compared to the bacteriological profile of HAIs. We identified lower gestational age, male gender and apgar score less than 7 at 5min, use of peripheral vascular catheter & ventilator along with their duration as significant risk factors. Mortality rate was 29% in the study group (p<0.05). The HAI site distribution showed blood-stream infections (73%) to be the most common followed by pneumonia (12%) and meningitis (10%). Gram positive cocci were the most common isolates in HAI as well as environmental surveillance. The bacteriological profile of HAI correlates with the environmental surveillance report thus insisting for periodic surveillance and thereby avoiding irrational antibiotic usage.

Complementary feeding at 4 versus 6 months of age for preterm infants born at less than 34 weeks of gestation: a randomised, open-label, multicentre trial

BACKGROUND

Evidence on the optimal time to initiation of complementary feeding in preterm infants is scarce. We examined the effect of initiation of complementary feeding at 4 months versus 6 months of corrected age on weight for age at 12 months corrected age in preterm infants less than 34 weeks of gestation.

METHODS

In this open-label, randomised trial, we enrolled infants born at less than 34 weeks of gestation with no major malformation from three public health facilities in India. Eligible infants were tracked from birth and randomly assigned (1:1) at 4 months corrected age to receive complementary feeding at 4 months corrected age (4 month group), or continuation of milk feeding and initiation of complementary feeding at 6 months corrected age (6 month group), using computer generated randomisation schedule of variable block size, stratified by gestation (30 weeks or less, and 31-33 weeks). Iron supplementation was provided as standard. Participants and the implementation team could not be masked to group assignment, but outcome assessors were masked. Primary outcome was weight for age Z-score at 12 months corrected age (WAZ12) based on WHO Multicentre Growth Reference Study growth standards. Analyses were by intention to treat. The trial is registered with Clinical Trials Registry of India, number CTRI/2012/11/003149.

FINDINGS

Between March 20, 2013, and April 24, 2015, 403 infants were randomly assigned: 206 to receive complementary feeding from 4 months and 197 to receive complementary feeding from 6 months. 22 infants in the 4 month group (four deaths, two withdrawals, 16 lost to follow-up) and eight infants in the 6 month group (two deaths, six lost to follow-up) were excluded from analysis of primary outcome. There was no difference in WAZ12 between two groups: -1·6 (SD 1·2) in the 4 month group versus -1·6 (SD 1·3) in the 6 month group (mean difference 0·005, 95% CI -0·24 to 0·25; p=0·965). There were more hospital admissions in the 4 month group compared with the 6 month group: 2·5 episodes per 100 infant-months in the 4 month group versus 1·4 episodes per 100 infant-months in the 6 month group (incidence rate ratio 1·8, 95% CI 1·0-3·1, p=0·03). 34 (18%) of 188 infants in the 4 month group required hospital admission, compared with 18 (9%) of 192 infants in the 6 month group.

INTERPRETATION

Although there was no evidence of effect for the primary endpoint of WAZ12, the higher rate of hospital admission in the 4 month group suggests a recommendation to initiate complementary feeding at 6 months over 4 months of corrected age in infants less than 34 weeks of gestation.

FUNDING

Indian Council of Medical Research supported the study until Nov 14, 2015. Subsequently, Shuchita Gupta's salary was supported for 2 months by an institute fellowship from All India Institute Of Medical Sciences, and a grant by Wellcome Trust thereafter.

C-reactive protein and parathyroid hormone in acute severe psychotic disorders (schizophrenia, bipolar disorder and methamphetamine-induced psychotic disorder)

Introduction

and objectives Schizophrenia accompanies with elevated C-reactive protein (CRP) and vitamin D deficiency. However, there are scarce documentations regarding bipolar disorder and methamphetamine-induced psychotic disorder.

Aim

To compare serum levels of vitamin D, parathyroid hormone (PTH), calcium, phosphorus and CRP levels in psychotic disorder patients and control group.

Methods

A case-control study was conducted on four groups: acute phase of schizophrenia, acute manic episode of bipolar disorder, methamphetamine-induced psychotic disorder and healthy control subjects. Sample size was 45 in each group. Weekly duration of sun exposure, monthly vitamin D intake and serum levels of vitamin D, calcium, phosphorus, PTH and CRP were assessed. Brief Psychiatric Rating Scale (BPRS) was used to evaluate psychotic symptoms.

Results

Duration of sun exposure and monthly vitamin D intake were comparable among groups. Serum levels of vitamin D, calcium and phosphorus were not statistically different between groups (P = 0.463, P = 0.086 and P = 0.339, respectively). Serum levels of PTH were significantly higher in control group (P < 0.001). CRP levels were significantly lower in control subjects (P < 0.001). The levels of serum vitamin D and CRP did not show statistically significant difference among three groups of patients.

Conclusion

Acute psychotic disorders seem to be associated with higher CRP and lower PTH levels. Clinical importance of the findings and relation of these differences to the metabolic and inflammatory bases of psychosis are not clear yet.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Is taxane/platinum/5 fluorouracil superior to taxane/platinum alone and does docetaxel trump paclitaxel in induction therapy for locally advanced oral cavity cancers?

BACKGROUND

Cisplatin and 5 fluorouracil drug combination is inferior to the combination of taxane with these 2 drugs. However, often in clinical practice at our center giving TPF (docetaxel, cisplatin, 5 fluorouracil) is difficult in view of logistics and tolerance issues. In such a scenario, we prefer to use the 2 drugs combination of platinum and taxane. However, no study has addressed whether a 2 drugs combination, which includes taxane is inferior to the 3 drugs combination and which the taxane of choice is in the 2 drugs combination of taxane and platinum.

METHODS

This is a retrospective analysis of prospectively collected data of patients undergoing induction chemotherapy (IC) in oral cavity cancers from 2010 to 2012. We chose for analysis those patients who had a baseline scan done within 4 weeks of starting therapy and a follow-up scan done within 2 weeks of completion of the second cycle of IC. Response was scored in accordance with RECIST version 1.1. Chi-square analysis was done to compare response rates (RRs) between regimens.

RESULTS

Two hundred and forty-five patients were identified. The median age was 45 years (24-70 years), 208 (84.9%) were male patients, and 154 patients (62.9%) had primary in the Buccal mucosa. The regimens received were TPF 22 (9%), docetaxel + cisplatin 97 (39.6%), paclitaxel + cisplatin 89 (36.3%), docetaxel + carboplatin 16 (6.5%) and paclitaxel + carboplatin 21 (8.6%). The overall RRs were complete response, partial response, stable disease and progressive disease in 4 (1.6%), 56 (22.9%), 145 (59.2%) and 40 (16.3%). The 3 drugs regimen (TPF) had 50% RR as compared to 22% RR with 2 drugs regimen (P = 0.004). Docetaxel containing regimens had 30.3% RR as compared to 17.2% RR with paclitaxel containing regimens (P = 0.094).

CONCLUSIONS

TPF has better RR than a 2 drugs taxane-containing regimen and docetaxel leads to a better RR than paclitaxel for IC in locally advanced oral cavity cancers.

Comparison of Human Neonatal and Adult Blood Leukocyte Subset Composition Phenotypes

The human peripheral leukocyte subset composition depends on genotype variation and pre-natal and post-natal environmental influence diversity. We quantified this composition in adults and neonates, and compared the median values and dispersal ranges of various subsets in them. We confirmed higher frequencies of monocytes and regulatory T cells (Tregs), similar frequencies of neutrophils, and lower frequencies of CD8 T cells, NKT cells, B1 B cells and gamma-delta T cells in neonatal umbilical cord blood. Unlike previous reports, we found higher frequencies of eosinophils and B cells, higher CD4:CD8 ratios, lower frequencies of T cells and iNKT cells, and similar frequencies of CD4 T cells and NK cells in neonates. We characterized monocyte subsets and dendritic cell (DC) subsets in far greater detail than previously reported, using recently described surface markers and gating strategies and observed that neonates had lower frequencies of patrolling monocytes and lower myeloid dendritic cell (mDC):plasmacytoid DC (pDC) ratios. Our data contribute to South Asian reference values for these parameters. We found that dispersal ranges differ between different leukocyte subsets, suggesting differential determination of variation. Further, some subsets were more dispersed in adults than in neonates suggesting influences of postnatal sources of variation, while some show the opposite pattern suggesting influences of developmental process variation. Together, these data and analyses provide interesting biological possibilities for future exploration.

Anencephaly with placental adhesion

Anencephaly is a serious neural tube defect, in which the brain and cranial vault are grossly malformed. It occurs due to failure of cranial neurulation during embryonic development of cranial tissues. Anomalous placental attachment on an anencephalic head of a newborn is extremely rare. We report two cases of anencephaly in which the placenta were anomalously attached on an anencephalic head.