Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment.

BACKGROUND: There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined. STUDY DESIGN: This retrospective case-control study including infants < 1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios. RESULTS: The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated. CONCLUSION: Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

Sudden versus gradual pressure wean from Nasal CPAP in preterm infants: a randomized controlled trial.

OBJECTIVE: In preterm infants, nasal continuous positive airway pressure (NCPAP) is widely used for treatment of respiratory distress syndrome. However, the strategies for successfully weaning infants off NCPAP are still not well defined and there remains considerable variation between the methods. The objective of this study is to determine whether gradual weaning of NCPAP pressure is more successful than sudden weaning off NCPAP to room air. STUDY DESIGN: A randomized controlled trial was conducted in a level 3 neonatal intensive care unit on 70 preterm neonates who were born between 26 and 32 weeks gestation and required NCPAP for at least 48 h. When infants were stable on NCPAP at 0.21 FiO2 and 5 cm H2O positive end expiratory pressure, neonates were randomized to the gradual wean group (reduction in pressure by 1 cm every 8 h until 3 cm H20 was reached) or to sudden wean group (one time NCPAP removal to room air). The primary outcome was a success at the first trial to wean to room air. Secondary outcomes were a number of trials, and weight and postmenstrual age (PMA) at the time of successful wean. Total number of days on NCPAP and length of stay (LOS) in the hospital were also compared between the groups. RESULTS: Of the 70 infants included in the study, 35 were randomized to sudden group and 33 infants to gradual group (2 excluded for protocol deviation). In sudden and gradual groups, 14 and 22 infants, respectively, were weaned successfully in the first attempt (P=0.03). The infants were successfully weaned at 32.7±1.7 weeks versus 33.1±2.4 weeks (P=0.39) PMA and at a weight of 1651±290 g versus 1589±398 g (P=0.46) in the sudden and gradual groups, respectively. The total number of days on NCPAP was 27±19 days versus 32±24 days (P=0.38) and LOS was 63±25 days versus 63±22 days (P=0.99) in the sudden and gradual groups, respectively. CONCLUSIONS: Gradual weaning method was more successful as compared to sudden weaning method in the initial trial off NCPAP. There was no difference in the PMA, weight at the time of successful wean, total days on NCPAP and LOS between the two groups.

A case of posterior shoulder dislocation with ipsilateral humeral shaft fracture.

Posterior shoulder dislocations are rare and represent 2-5% of all traumatic shoulder dislocation. A combination of this injury with ipsilateral humeral shaft fracture is extremely rare event. We here report a case of posterior shoulder dislocation with ipsilateral fracture shaft of humerus following road traffic accident. Through this report, we highlight the rarity of the condition and review the available literature on the subject. We also emphasize the importance of complete physical and radiological examination when dealing with such cases to ensure early detection and its subsequent treatment.

The prevalence of vitamin D deficiency and its relationship with disease severity in an urban pediatric critical care unit.

OBJECTIVE: To evaluate the prevalence of vitamin D deficiency among patients admitted to a Pediatric Critical Care Unit (PCCU) in an urban children's hospital, and to assess if there is a correlation between vitamin D level and disease severity. PATIENTS AND METHODS: Patients (216) between the ages of 1-21 years admitted to the PCCU in a children's hospital, excluding those readmitted with a previous vitamin D level, were enrolled. Serum 25-OH vitamin D levels were measured in all patients within 24 h of admission to the PCCU. The severity of patient illness was assessed by the Pediatric Logistic Organ Dysfunction (PELOD) score determined on admission. RESULTS: Vitamin D deficiency was found in 28% of patients and vitamin D insufficiency was found in 47% of patients. Adolescent age group, female gender, Black race, winter season, and increasing BMI were determined to be risk factors associated with vitamin D deficiency. No significant correlation was found between vitamin D level and PELOD score (p=0.09). There were six deaths (3%), 5 (83%) of which occurred in patients with low vitamin D levels. Total serum calcium levels correlated with vitamin D (p=0.005) and PELOD score (p=0.001). However, ionized calcium levels did not significantly correlate with vitamin D (p=0.62) or PELOD score (p=0.26). CONCLUSIONS: Vitamin D deficiency is common in children admitted to an urban inner city PCCU, with 75% of patients having abnormal levels. We did not find a significant correlation between disease severity as measured by PELOD score and vitamin D level in a heterogeneous group of critically ill children. Total serum calcium levels significantly correlated with vitamin D and disease severity in this population. There appears to be an association between vitamin D deficiency and mortality.

Prescription habits for preventative medications among pediatric emergency department physicians at an inner-city teaching hospital.

INTRODUCTION: As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored. METHODS: We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice. RESULTS: Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification. CONCLUSIONS: We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.

Comparison of asthma knowledge, management, and psychological burden among parents of asthmatic children from rural and urban neighborhoods in India.

INTRODUCTION: Asthma prevalence is increasing in developing countries such as India. Little is known on parental knowledge of asthma severity, management and psychosocial impact, particularly among rural dwellers. Further, it is not known whether the female asthmatic child is particularly vulnerable. OBJECTIVE: To evaluate parental asthma knowledge and psychological impact of having an asthmatic child. METHODS: 134 consecutive caregivers were surveyed at the visit for their child's asthma exacerbation at an urban hospital in Kanpur, India between 3/2007-3/2008. RESULTS: The child's age range was 5.7A +/- 2.7 years. 76% were urban city dwellers with significantly higher number having a college degree. 23% children had moderate to severe persistent asthma; however, only 42% were on inhaled steroids. Parental severity perception was comparable to National Heart, Lung and Blood Institute (NHLBI) classification. While 67% identified bronchoconstriction occurred with asthma, only 8.9% recognized that inflammation played a role. There was no difference in the perceived stress by area of residence with 89% reported not or only sometimes feeling stressed with having an asthmatic child. Similarly, the concern among those with a female asthmatic child did not differ with 73% of caregivers believing that asthma would not affect their daughter's future. CONCLUSION: In an urban Indian hospital, 23% of asthmatic children had moderate to severe persistent asthma but only 9% were on controllers. Their parents were well educated, able to identify asthma severity appropriately and denied being stressed with having asthmatic children, irrespective of the gender of the child. However, their understanding of asthma pathophysiology was sub-optimal. Increased disease knowledge may lead to greater medication adherence among asthmatic children in India.

Primitive neuroectodermal tumour of the prostate gland: ultrasound and MRI findings.

We report a rare case of primitive neuroectodermal tumour (PNET) of the prostate occurring in a 26-year-old man with a mass replacing the prostate gland in the absence of any lesion involving the bone and soft tissues. To our knowledge, there is no radiological literature that has described the imaging findings in a case of PNET of the prostate. Imaging findings in cases of PNET of the kidney are described in the literature. On ultrasound, the mass appeared multilobulated and multinodular with intratumoural heterogeneity. No brightly reflective echoes with posterior acoustic shadowing to suggest calcification were noted. MRI revealed a heterogeneous lobulated mass with irregular septae within. The mass showed low signal intensity on T(1) weighted images and appeared heterogeneous on T(2) weighted images. Haemorrhage and necrosis were also seen in the tumour.

A systematic review of the quality of homeopathic pathogenetic trials published from 1945 to 1995.

BACKGROUND: The quality of information gathered from homeopathic pathogenetic trials (HPTs), also known as 'provings', is fundamental to homeopathy. We systematically reviewed HPTs published in six languages (English, German, Spanish, French, Portuguese and Dutch) from 1945 to 1995, to assess their quality in terms of the validity of the information they provide. METHODS: The literature was comprehensively searched, only published reports of HPTs were included. Information was extracted by two reviewers per trial using a form with 87 items. Information on: medicines, volunteers, ethical aspects, blinding, randomization, use of placebo, adverse effects, assessments, presentation of data and number of claimed findings were recorded. Methodological quality was assessed by an index including indicators of internal and external validity, personal judgement and comments of reviewers for each study. RESULTS: 156 HPTs on 143 medicines, involving 2815 volunteers, produced 20,538 pathogenetic effects (median 6.5 per volunteer). There was wide variation in methods and results. Sample size (median 15, range 1-103) and trial duration (mean 34 days) were very variable. Most studies had design flaws, particularly absence of proper randomization, blinding, placebo control and criteria for analysis of outcomes. Mean methodological score was 5.6 (range 4-16). More symptoms were reported from HPTs of poor quality than from better ones. In 56% of trials volunteers took placebo. Pathogenetic effects were claimed in 98% of publications. On average about 84% of volunteers receiving active treatment developed symptoms. The quality of reports was in general poor, and much important information was not available. CONCLUSIONS: The HPTs were generally of low methodological quality. There is a high incidence of pathogenetic effects in publications and volunteers but this could be attributable to design flaws. Homeopathic medicines, tested in HPTs, appear safe. The central question of whether homeopathic medicines in high dilutions can provoke effects in healthy volunteers has not yet been definitively answered, because of methodological weaknesses of the reports. Improvement of the method and reporting of results of HPTs are required. REFERENCES: References to all included RCTs are available on-line at.

T-helper type 2 polarization among asthmatics during and following pregnancy.

BACKGROUND: Asthma is the most common medical condition during pregnancy. While increased production of T helper cytokines has been reported to occur in both asthma and pregnancy, the effect of T-helper type 2 (Th2) polarization on asthma symptoms during pregnancy has not been well-characterized. OBJECTIVE: We hypothesized that systemic Th2 cytokine and chemokine polarization occurs among asthmatics to a greater extent during their pregnancy, and is associated with more severe asthma and increased Th2 polarization in the newborn. METHODS: Fifty-six pregnant asthmatics were recruited from prenatal clinics affiliated with New York Presbyterian Hospital. Systemic production of interleukin-4, interferon-gamma, eotaxin and IP10 were measured by intracytoplasmic staining or ELISA at recruitment, peripartum and post-partum, and in the cord blood. The frequency of asthma symptoms was measured by questionnaires and compared with Th biomarkers. RESULTS: The chemokine ratio (IP10/eotaxin) declined over the course of pregnancy (from 3.3 +/- 1.3 to 1.4 +/- 0.2, P = 0.016), but IP10 and eotaxin increased post-partum. The decrease in the chemokine ratio was associated with more frequent asthma symptoms. A non-significant trend towards decreased interferon-gamma and increased interleukin-4 production was detected. Cord blood eotaxin levels correlated with maternal levels (r = 0.35, P = 0.03). Other peripartum biomarkers were not associated with Th2 polarization nor with subsequent respiratory symptoms in the newborn. CONCLUSION: IP10/eotaxin declined over the course of pregnancy and was associated with worse asthma symptoms. Alterations of Th1/Th2 chemokine balance during pregnancy may identify women prone to more severe asthma during pregnancy.

Host-bacterial interactions in the initiation of inflammation.

The respiratory epithelium provides both a physical and an immunological barrier to inhaled pathogens. In the normal host, innate defences prevent bacteria from activating inflammation by providing efficient muco-ciliary clearance and antimicrobial activity. Bacteria that persist in the airway lumen, as in cystic fibrosis, activate both the professional immune cells in the respiratory mucosa as well as the more abundant airway epithelial cells. As most of the bacteria become entrapped in airway mucin, shed bacterial products such as pili, flagella, peptidoglycan and lipopolysaccharide from lysed bacteria are likely to be the stimuli most important in activating epithelial signalling. The airway cells respond briskly to bacterial components through several signalling systems which activate epithelial expression of pro-inflammatory cytokines and chemokines. These signals recruit neutrophils to the airways where they eliminate the contaminating bacteria causing inflammation and the ensuing clinical signs of infection.

Leukemoid reaction in extremely low-birth-weight infants.

The objective of this paper was to determine the incidence of leukemoid reaction and to evaluate its relationship with maternal and neonatal factors in extremely low-birth-weight (ELBW) infants. The design a case-controlled retrospective study of all live-born ELBW infants (<1000 g) over a period of 2 years, from July 1994 to June 1996. A total of 60 preterm infants were born during the study period, and are included in this report. The infants who demonstrated leukemoid reaction formed the study group, while the remainder formed the control group. Leukemoid reaction was defined as a white blood cell (WBC) count > or = 50,000/mm3. The relationship between maternal and neonatal variables and WBC counts was studied. Nine of the 60 infants studied demonstrated counts >50,000/mm3, with an incidence of 15%. There was no significant association demonstrated between maternal or neonatal variables and leukemoid reaction. Patients with leukemoid reaction had a better overall survival. Leukemoid reaction in ELBW infants is a rare and recently documented phenomenon. In our study the incidence was 15%. Although many factors have been postulated as a cause of this phenomenon, we could not demonstrate any relationship between these factors and high WBC counts, including sepsis and the use of antenatal steroids, the two most likely variables. It was interesting to note that the infants who were able to mount a leukemoid response had a better chance of survival than those who did not.

Homeopathy in HIV infection: a trial report of double-blind placebo controlled study.

OBJECTIVE: This study was aimed to evaluate the immuno-modulator role of homeopathic remedies in Human Immunodeficiency Virus (HIV) infection. METHODOLOGY: A randomised double blind clinical trial was conducted to compare the effect of homeopathic remedies with placebo, on CD4+ve T-lymphocytes in HIV infected individuals, conforming to Centres for Disease Control (CDC) stage II & III. 100 HIV+ve individuals between 18-50 y (71% males) were included in the study. 50 cases conformed to CDC stage II--Asymptomatic HIV infection, and 50 cases to CDC stage III--Persistent Generalised Lymphadenopathy (PGL). Cases were stratified according to their clinical status and CD4+ve lymphocyte counts. The randomisation charts were prepared much before the start of the trial by randomly assigning placebo and verum codes to registration numbers from 1 to 50. A single individualised homeopathic remedy was prescribed in each case and was followed up at intervals of 15 d to one month. A six months study was performed for each registered case. Assessment of progress was made by evaluation of CD+ve lymphocyte counts, which was the prospectively-defined main outcome measure of the study; the results were compared with the base line immune status. RESULTS: In PGL, a statistically significant difference was observed in CD+ve T-lymphocyte counts between pre and post trial levels in verum group (P < 0.01). In the placebo group a similar comparison yielded non-significant results. (P = 0.91). Analysis of change in the pre and post trial counts of CD4+ve cells between groups was also statistically significant (P = 0.04). In asymptomatic HIV infection, differences in absolute CD4+ve lymphocyte counts between pre and post trial levels were not significant. Analysis of changes in pre and post trial CD4 levels of placebo and verum groups for combined strata of asymptomatic and PGL groups was also not significant. CONCLUSION: The study suggests a possible role of homeopathic treatment in HIV infection in symptomatic phase, as evidenced by a statistically significant elevation of base line immune status in persistent generalised lymphadenopathy.

Pseudohypoparathyroidism-Albright hereditary osteodystrophy.

A 13 year old girl with short stature, and retarded mental growth with coarse facies and deranged thyroid function test was initially suspected as a case of hypothyroidism and was started on thyroxine. Lack of response to treatment and on further investigations it was diagnosed as a case of pseudohypoparathyroidism. High index of suspicion and careful evaluation is important to diagnose such an entity.

Uncoupling of oxidative phosphorylation does not induce thermotolerance in cultured Chinese hamster cells.

Two uncouplers of oxidative phosphorylation, 2,4-dinitrophenol (DNP) and carbonyl cyanide m-chlorophenylhydrazone (CCCP), were tested for their ability to modify the survival of cultured Chinese hamster ovary (CHO) and Chinese hamster V79 cells treated with hyperthermia. The uncouplers were used under conditions that inhibit oxidative ATP synthesis, as judged from measurements of cellular ATP levels. Incubation of CHO cells in glucose-free Hanks' balanced salt solution (HBSS) containing 1 mM DNP for 1 h at 37 degrees C followed by reincubation at 37 degrees C in complete growth medium for 3 or 16 h, showed no substantial changes in the 45 degrees C heat survival curve as compared to heated cells not exposed to DNP. Thus, DNP treatment of CHO cells did not induce thermotolerance. Carbonyl cyanide m-chlorophenylhydrazone (CCCP), tested under similar experimental conditions, did alter cellular heat resistance. The major change in the 45 degrees C survival curve of CHO cells pretreated with CCCP was an increase in the width of the shoulder: the Dq value increased from 14 min to 24 min, for the control and CCCP-treated cells respectively. The D0 value did not change appreciably. In contrast, heat-induced thermotolerance (10 min, 45 degrees C + 16 h, 37 degrees C) was characterized primarily by an increase in the D0 parameter from 4 min (unheated cells) to 17 min. Similar results were observed with CCCP-treated V79 cells. The data demonstrate that heat resistance induced by 1.2 microM CCCP was manifest as an increased cellular capacity to accumulate and/or repair hyperthermia damage, rather than an induction of thermotolerance, and that this effect probably was not related to the action of CCCP as an uncoupler of oxidative phosphorylation.

Development of thermotolerance in CHO cells: modification by procaine.

We have tested the reported ability of procaine to inhibit the induction and the development of thermotolerance in Chinese hamster ovary cells. Thermotolerance was induced either by hyperthermia alone (10 min, 45 degrees C) or by combining hyperthermia and procaine (5 min, 45 degrees C + 10 mM procaine) with heating times adjusted to yield similar cell survival after the conditioning treatments. Both the kinetics of thermotolerance development in fresh medium without procaine and the magnitude of thermotolerance 6 h after heat conditioning were similar for the two treatment groups. Development of thermotolerance in the presence of procaine was tested by adding the drug at 5 or 10 mM to culture medium between, but not during two fractionated heat treatments. Thermotolerance development was observed even in the presence of 10 mM procaine, but only if cell survival was corrected for the 37 degrees C-procaine toxicity. Complete survival curves of cells incubated for 6 h at 37 degrees C in 7.5 mM procaine between heat conditioning and test heating showed a D0 that was only 35 per cent lower than that of thermotolerant controls. The data are consistent with the reported sensitization to heat killing by procaine, but show that thermotolerance induction and development were only minimally perturbed by procaine.