Pulmonary hypertension in preterm infants with moderate-to-severe bronchopulmonary dysplasia (BPD).

AIM: To describe clinical characteristics of pulmonary hypertension (PH) associated with moderate to severe BPD (MSBPD) in premature infants born ≤32 weeks gestation. METHODS: This was a single centre retrospective cohort study, with reanalysis of echocardiographic studies for PH of infants born ≤32 weeks gestation with MSBPD admitted to a tertiary surgical neonatal service. RESULTS: In total, 268 babies with MSBPD were included in the study. Incidence of BPD-associated PH (BPD-PH) was 12.6% (34), of which 41% infants were observed to have severe PH. On multivariate analysis, need for positive pressure respiratory support at 36 weeks post menstrual age (PMA) was independently associated with PH (p = 0.001; 95% CI 2-13.5) Presence of PH and severity of PH were associated with increased mortality. Of babies with MSBPD-PH, 32% died before discharge from the neonatal unit. CONCLUSION: Babies with MSBPD and PH are more likely to die before discharge from the neonatal unit. Need for positive pressure respiratory support at 36 weeks PMA is independently associated with PH. Babies with MSBPD with less than severe PH are also associated with increased mortality when compared to babies with MSBPD with no PH.

Improved respiratory parameters with skin-to-skin contact in premature infants with bronchopulmonary dysplasia on NIV-NAVA.

AIM: To determine if skin-to-skin contact (SSC) improved respiratory parameters in premature infants with evolving or established bronchopulmonary dysplasia (BPD) on non-invasive neutrally adjusted ventilator assist (NIV-NAVA). METHODS: Premature infants (<32 weeks gestational age) with BPD on NIV-NAVA were studied. Continuous readings from the Edi catheter (modified nasogastric feeding tube inserted for NAVA ventilation) were compared: pre-SSC (baby in incubator) and end-SSC (just before end of SSC). RESULTS: Sixty-five episodes of SSC were recorded in 12 premature infants with median gestational age at birth of 24.4 (23.1-27.0) weeks and birth weight of 642 (530-960) grams. Peak Edi (uV) in end-SSC 11.5 (2.7-38.7) was significantly lower compared to pre-SSC 15.8 (4.0-36.6), p < 0.001. P mean (cmH2 O) was significantly lower in end-SSC 9.7 (7.3-15.4) compared to pre-SSC 10.3 (7.5-15.5), p = 0.008. Respiratory rate (breaths/min) was significantly lower in end-SSC 52.9 (31.1-78.1) compared to pre-SSC 53.4 (35.1-74.1), p = 0.031. There was no significant difference in inspired oxygen requirement or time on back-up mode in end-SSC 40.0 (22.1-56.1) and 5.9 (0.0-56.0) compared to pre-SSC 39.0 (26.0-56.1) and 5.1 (0.0-29.3), p = 0.556 and p = 0.853 respectively. CONCLUSION: SSC improved respiratory parameters in premature infants with evolving or established BPD on NIV-NAVA.

Comparison of Outcomes of Less Invasive Surfactant Administration in Prematurely Born Infants in the Delivery Suite and the Neonatal Unit.

OBJECTIVE: This study aimed to compare outcomes of infants who received less invasive surfactant administration (LISA) in the delivery suite (LISA-DS) with those who received LISA on the neonatal unit (LISA-NNU). STUDY DESIGN: A prospective cohort study was undertaken of all infants who received LISA in a single center. Clinical outcomes included admission temperature, the need for intubation, durations of invasive and noninvasive ventilation, length of hospital stay and the incidences of bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and requirement for home oxygen were compared between the two groups as were complications of the procedure. RESULTS: The 54 LISA-DS infants had similar gestational ages and birth weights to the 26 LISA-NNU infants (p = 0.732, 0.928, respectively). There were no significant differences between the admission temperatures (median [range]: 36.8 [36-38.7] vs. 36.8°C [36.4-37.7]; p = 0.451) or need for intubation in less than 72 hours of birth (28 vs. 23%, p = 0.656). The durations of invasive ventilation (median: 2 [0-65] vs. 1 [0-35] days; p = 0.188) and noninvasive ventilation (median: 37 [24-81] vs. 37 [3-225] days; p = 0.188) and the incidences of BPD (p = 0.818), IVH (p = 0.106), ROP (p = 0.526), and home oxygen requirement (p = 0.764) were similar. The percentage of successful first attempts with LISA (63 vs. 70%, p = 0.816) or associated with hypoxia episodes (32 vs. 42%, p = 0.194) did not differ significantly by site of administration. CONCLUSION: The outcomes of LISA performed on the DS were similar to those of LISA performed on the NNU. KEY POINTS: · Prematurely born infants who received LISA in the DS had comparable clinical outcomes to infants who received LISA on NNU.. · No significant differences in admission temperature was noticed in infants who received LISA, in DS versus NNU..

Improved nutritional outcomes with neurally adjusted ventilatory assist (NAVA) in premature infants: a single tertiary neonatal unit's experience.

During neurally adjusted ventilatory assist (NAVA)/non-invasive (NIV) NAVA, a modified nasogastric feeding tube with electrodes, monitors the electrical activity of the diaphragm (Edi). The Edi waveform determines the delivered pressure from the ventilator. Infant breathing is in synchrony with the ventilator and therefore is more comfortable with less work of breathing. Our aim was to determine if infants on NAVA had improved nutritional outcomes compared to infants managed on conventional respiratory support. A retrospective study was undertaken. Infants on NAVA were matched with two conventionally ventilated controls by gestational age, birth weight, sex, antenatal steroid exposure, and whether inborn or transferred ex utero. NAVA/NIV-NAVA was delivered by the SERVO-n® Maquet Getinge group ventilator. Conventional ventilation included pressure and volume control ventilation, and non-invasive ventilation included nasal intermittent positive pressure ventilation, triggered biphasic positive airway pressure, continuous positive airway pressure and heated humidified high flow oxygen. The measured outcome was discharge weight z scores. Eighteen "NAVA" infants with median gestational age (GA) of 25.3 (23.6-27.1) weeks and birth weight (BW) of 765 (580-1060) grams were compared with 36 controls with GA 25.2 (23.4-28) weeks (p = 0.727) and BW 743 (560-1050) grams (p = 0.727). There was no significant difference in the rates of postnatal steroids (61% versus 36% p = 0.093), necrotising enterocolitis (22% versus 11% p = 0.279) in the NAVA/NIV NAVA compared to the control group. There were slightly more infants who were breastfed at discharge in the NAVA/NIV NAVA group compared to controls: breast feeds (77.8% versus 58.3%), formula feeds (11.1% versus 30.6%), and mixed feeds (11.1% versus 11.1%), but this difference was not significant (p = 0.275). There was no significant difference in the birth z scores 0.235 (-1.56 to 1.71) versus -0.05 (-1.51 to -1.02) (p = 0.248) between the groups. However, the discharge z score was significantly in favour of the NAVA/NIV-NAVA group: -1.22 (-2.66 to -0.12) versus -2.17 (-3.79 to -0.24) in the control group (p = 0.033).Conclusion: The combination of NAVA/NIV-NAVA compared to conventional invasive and non-invasive modes may contribute to improved nutritional outcomes in premature infants.

The use of neurally-adjusted ventilatory assist (NAVA) for infants with congenital diaphragmatic hernia (CDH).

OBJECTIVES: Newborns with congenital diaphragmatic hernia (CDH) can have complex respiratory problems which are worsened by ventilatory induced lung injury. Neurally adjusted ventilator assist (NAVA) is a potentially promising ventilation mode for this population, as it can result in improved patient-ventilator interactions and provision of adequate gas exchange at lower airway pressures. CONTENT: A literature review was undertaken to provide an overview of NAVA and examine its role in the management of infants with CDH. SUMMARY: NAVA in neonates has been used in CDH infants who were stable on ventilatory support or being weaned from mechanical ventilation and was associated with a reduction in the level of respiratory support. OUTLOOK: There is, however, limited evidence regarding the efficacy of NAVA in infants with CDH, with only short-term benefits being investigated. A prospective, multicentre study with long term follow-up is required to appropriately assess NAVA in this population.

Impact of a Care Bundle on Cost Saving for Noninvasive Respiratory Support for Neonates.

BACKGROUND: Neonates often receive noninvasive respiratory support via continuous positive airway pressure (CPAP) or high-flow nasal cannula oxygen (HHFNC). The decision to change from one mode to the other, however, is not evidence based, hence not standardized and does not consider cost implications. PURPOSE: To assess the introduction of a care bundle for the medical and nursing staff in a tertiary medical and surgical neonatal center with regard to any financial savings or adverse outcomes. METHODS: An education package and written guidelines were used to increase the awareness of the durations for which CPAP and HHFNC Vapotherm (VT) circuits could be used and the costs of the circuits. RESULTS: This resulted in a cost saving of £17,000 ($22,254) for the year without adverse outcomes. IMPLICATIONS FOR PRACTICE: Introduction of a care bundle involving an education package and written guidelines to increase the awareness of the durations that circuits could be used and the costs of CPAP and HHFNC circuits among the medical and nursing staff can lead to cost savings when incorporated into clinical practice. IMPLICATIONS FOR RESEARCH: Strategies, particularly during weaning, which involve changing from one form of noninvasive respiratory support to another, need a greater evidence base. Future research should include awareness of the duration different circuits could be used and the cost implications of changes between modes and hence circuits.

Tidal Volumes and Outcome of Extubation in Mechanically Ventilated Premature Infants.

OBJECTIVES: To compare the adjusted and unadjusted-for-weight tidal volume (VT) in ventilated prematurely born infants who were successfully extubated compared with the ones who failed extubation and explore the ability of VT to predict successful extubation. STUDY DESIGN: This is a two-center, prospective, observational, cohort study of ventilated infants born <32 weeks of gestational age (GA) at King's College Hospital and St George's University Hospital, London, United Kingdom between February and September 2018. Expiratory VT was recorded before extubation, and extubation was considered successful if the infants were not reintubated within 72 hours. RESULTS: Fifty-six (29 male) infants with a median (interquartile range) GA of 26 (25-29) weeks were studied. The infants who successfully extubated (N = 36) had a higher GA (27 [25-30] weeks) and VT (7.2 [4.8-9.5] mL) compared with the GA (25 [24-26] weeks) and VT (4.3 [4.0-5.5] mL) of the infants who failed extubation (p = 0.002 and p = 0.001, respectively). VT/kg was not different in infants who successfully extubated compared with the ones who failed extubation (p = 0.643). Following multivariate regression, VT was associated with extubation success (adjusted p = 0.022) and GA was not (adjusted p = 0.167). A VT > 4.5 mL predicted successful extubation with 82% sensitivity and 58% specificity (area under the curve = 0.786). CONCLUSION: Successful extubation was associated with higher unadjusted-for-weight VTs compared with failed extubation, and unadjusted VT predicted extubation outcome with moderate sensitivity and specificity.

Crossover study of assist control ventilation and neurally adjusted ventilatory assist.

Some studies of infants with acute respiratory distress have demonstrated that neurally adjusted ventilator assist (NAVA) had better short-term results compared to non-triggered or other triggered models. We determined if very prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD) had a lower oxygenation index (OI) on NAVA compared to assist control ventilation (ACV). Infants were studied for 1 h each on each mode. At the end of each hour, blood gas analysis was performed and the OI calculated. The inspired oxygen concentration (FiO2), the peak inflation (PIP) and mean airway pressures (MAP) and compliance were averaged from the last 5 min on each mode. Nine infants, median gestational age of 25 (range 22-27) weeks, were studied at a median postnatal age of 20 (range 8-84) days. The mean OI after 1 h on NAVA was 7.9 compared to 11.1 on ACV (p = 0.0007). The FiO2 (0.36 versus 0.45, p = 0.007), PIP (16.7 versus 20.1 cm H2O, p = 0.017) and MAP (9.2 versus 10.5 cm H2O, p = 0.004) were lower on NAVA. Compliance was higher on NAVA (0.62 versus 0.50 ml/cmH2O/kg, p = 0.005). CONCLUSION: NAVA compared to ACV improved oxygenation in prematurely born infants with evolving or established BPD. What is Known: • Neurally assist ventilator adjust (NAVA) uses the electrical activity of the diaphragm to servo control the applied pressure. • In infants with acute RDS, use of NAVA was associated with lower peak inflation pressures and higher tidal volumes. What is New: • This study uniquely reports infants with evolving or established BPD, and their results were compared on 1 h each of NAVA and assist controlled ventilation. • On NAVA, infants had superior (lower) oxygen indices, lower inspired oxygen concentrations and peak and mean airway pressures and higher compliance.

Neurally adjusted ventilatory assist compared to other forms of triggered ventilation for neonatal respiratory support.

BACKGROUND: Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially reducing barotrauma and volutrauma and development of air leaks and bronchopulmonary dysplasia. During neurally adjusted ventilatory assist ventilation (NAVA), respiratory support is initiated upon detection of an electrical signal from the diaphragm muscle, and pressure is provided in proportion to and synchronous with electrical activity of the diaphragm (EADi). Compared to other modes of triggered ventilation, this may provide advantages in improving synchrony. OBJECTIVES: Primary• To determine whether NAVA, when used as a primary or rescue mode of ventilation, results in reduced rates of bronchopulmonary dysplasia (BPD) or death among term and preterm newborn infants compared to other forms of triggered ventilation• To assess the safety of NAVA by determining whether it leads to greater risk of intraventricular haemorrhage (IVH), periventricular leukomalacia, or air leaks when compared to other forms of triggered ventilation Secondary• To determine whether benefits of NAVA differ by gestational age (term or preterm)• To determine whether outcomes of cross-over trials performed during the first two weeks of life include peak pressure requirements, episodes of hypocarbia or hypercarbia, oxygenation index, and the work of breathing SEARCH METHODS: We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cohrane Library; MEDLINE via Ovid SP (January 1966 to March 2017); Embase via Ovid SP (January 1980 to March 2017); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to March 2017); and the Web of Science (1985 to 2017). We searched abstracts from annual meetings of the Pediatric Academic Societies (PAS) (2000 to 2016); meetings of the European Society of Pediatric Research (published in Pediatric Research); and meetings of the Perinatal Society of Australia and New Zealand (PSANZ) (2005 to 2016). We also searched clinical trials databases to March 2017. SELECTION CRITERIA: We included randomised and quasi-randomised clinical trials including cross-over trials comparing NAVA with other modes of triggered ventilation (assist control ventilation (ACV),synchronous intermittent mandatory ventilation plus pressure support (SIMV ± PS), pressure support ventilation (PSV), or proportional assist ventilation (PAV)) used in neonates. DATA COLLECTION AND ANALYSIS: Primary outcomes of interest from randomised controlled trials were all-cause mortality, bronchopulmonary dysplasia (BPD; defined as oxygen requirement at 28 days), and a combined outcome of all-cause mortality or BPD. Secondary outcomes were duration of mechanical ventilation, incidence of air leak, incidence of IVH or periventricular leukomalacia, and survival with an oxygen requirement at 36 weeks' postmenstrual age.Outcomes of interest from cross-over trials were maximum fraction of inspired oxygen, mean peak inspiratory pressure, episodes of hypocarbia, and episodes of hypercarbia measured across the time period of each arm of the cross-over. We planned to assess work of breathing; oxygenation index, and thoraco-abdominal asynchrony at the end of the time period of each arm of the cross-over study. MAIN RESULTS: We included one randomised controlled study comparing NAVA versus patient-triggered time-cycled pressure-limited ventilation. This study found no significant difference in duration of mechanical ventilation, nor in rates of BPD, pneumothorax, or IVH. AUTHORS' CONCLUSIONS: Risks and benefits of NAVA compared to other forms of ventilation for neonates are uncertain. Well-designed trials are required to evaluate this new form of triggered ventilation.

Volume-targeted versus pressure-limited ventilation in infants born at or near term.

Our aims were to determine whether volume-targeted ventilation (VTV) or pressure-limited ventilation (PLV) reduced the time to successful extubation and if any difference was explained by a lower work of breathing (WOB), better respiratory muscle strength or less thoracoabdominal asynchrony (TAA) and associated with fewer hypocarbic episodes. Infants born at ≥34 weeks of gestational age were randomised to VTV or PLV. The WOB was assessed by the transdiaphragmatic pressure time product, respiratory muscle strength by the maximum inflation (Pimax) and expiratory (Pemax) pressures and TAA assessed using uncalibrated respiratory inductance plethysmography. Forty infants, median gestational age of 39 (range 34-42) weeks, were recruited. The time to successful extubation did not differ between the two groups (median 25, range 2.5-312 h (VTV) versus 33.5, 1.312 h (PLV)) (p = 0.461). There were no significant differences between the groups with regard to the WOB, respiratory muscle strength or the TAA results. The median number of hypocarbic episodes was 1.5 (range 0-8) in the VTV group versus 4 (range 1-13) in the PLV group (p = 0.005). CONCLUSION: In infants born at or near term, VTV compared to PLV did not reduce the time to successful extubation but was associated with significantly fewer hypocarbic episodes. WHAT IS KNOWN: In prematurely born infants, volume-targeted ventilation (VTV) compared to pressure-limited ventilation (PLV) reduces bronchopulmonary dysplasia or death. In addition, VTV is associated in prematurely born infants with lower incidences of pneumothorax, intraventricular haemorrhage and hypocarbic episodes. WHAT IS NEW: Despite a high morbidity, few studies have investigated optimum ventilation strategies for infants born at or near term. In a RCT, we have demonstrated VTV versus PLV in infants ≥34 weeks gestation was associated with significantly fewer hypocarbic episodes.

Proportional assist versus assist control ventilation in premature infants.

During proportional assist ventilation (PAV), the applied pressure is servo-controlled based on continuous input from the infant's breathing. In addition, elastic and resistive unloading can be employed to compensate for the abnormalities in the infant's lung mechanics. The aim of this study was to test the hypothesis that in very prematurely born infants remaining ventilated beyond the first week, PAV compared to assist control ventilation (ACV) would be associated with superior oxygenation. A randomised crossover study was undertaken. Infants were studied for 4 hours each on PAV and ACV in random order; at the end of each 4-h period, the oxygenation index (OI) was calculated. Eight infants, median gestational age of 25 (range 24-33) weeks, were studied at a median of 19 (range 10-105) days. It had been intended to study 18 infants but as all the infants had superior oxygenation on PAV (p = 0.0039), the study was terminated after recruitment of eight infants. The median inspired oxygen concentration (p = 0.049), mean airway pressure (p = 0.012) and OI (p = 0.012) were all lower on PAV. CONCLUSION: These results suggest that PAV compared to ACV is advantageous in improving oxygenation for prematurely born infants with evolving or established BPD. WHAT IS KNOWN: During proportional assist ventilation (PAV), the applied pressure is servo controlled throughout each spontaneous breath. Elastic and resistive unloading can compensate for the infant's abnormalities in lung mechanics. WHAT IS NEW: In a randomised crossover study, infants with evolving/established BPD were studied on PAV and ACV each for 4 h. The oxygenation index was significantly lower on PAV in all infants studied.

Presurgical Nasoalveolar Molding Therapy Using Figueroa's NAM Technique in Unilateral Cleft Lip and Palate Patients: A Preliminary Study.

OBJECTIVE: The objective of the study was to evaluate the results of nasoalveolar molding (NAM) in the treatment of patients with unilateral cleft lip and palate using a modified technique in a South Indian population. STUDY DESIGN: The design was a prospective study with blinded measurements. The sample constituted 10 complete unilateral cleft lip and palate (UCLP) patients who underwent NAM therapy by the same operator. Direct extra and intra oral anthropometric measurements were done using a digital vernier caliper before and after NAM therapy. A photographic evaluation was also done to rate the nasal deformity post NAM therapy. The differences between measurements were statistically analyzed using paired t tests. RESULTS: The extra oral measurements revealed a statistically significant increase in bi-alar width, columellar length and width. The intraoral measurements demonstrated a statistically significant reduction in anterior alveolar cleft width. There was also a significant increase in arch width and greater and lesser segments length. All cases were rated as improved by the surgeons in photographic analysis. CONCLUSION: The study has quantitatively shown that the modified NAM therapy improved nasal asymmetry by columellar lengthening and effectively molded the maxillary alveolar arch.

The Nasal Microarchitecture: How Does Tracheostomy Affect it?

This study aims to evaluate the histological changes in the nasal mucosa post Tracheostomy. A prospective observational study was done on 30 patients undergoing Tracheostomy after obtaining written informed consent from patients/legally accepted representatives. Prior to Tracheostomy, anterior rhinoscopy was done, and findings were noted; nasal mucosal biopsy was obtained from the inferior turbinate. The patients enrolled were followed up for four weeks, and in the patients still having Tracheostomy, repeat inferior turbinate biopsies were taken and compared. Statistically significant atrophy of lining epithelium was seen in 80% of the subjects, i.e., pseudostratified lining epithelium at Baseline with multilayered appearance changed to a single layer of flattened cells at follow-up. There was also a marked reduction in the number of seromucinous glands in the stroma at follow-up in 80% of the subjects. Additionally, fibrosis in the stroma was noted in 43.3% of subjects at follow-up. The results from this study indicate that Tracheostomy, likely as a result of nasal airflow deprivation, brings about significant changes in the microanatomy of the nasal airway. The extent of this causation and its implication in nasal pathology must be studied in larger populations with extended follow-up periods.

Study protocol for a randomised cross-over trial of Neurally adjusted ventilatory Assist for Neonates with Congenital diaphragmatic hernias: the NAN-C study.

BACKGROUND: Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers oxygen pressures in proportion to electrical signals of the diaphragm. The proportional assistance can be adjusted by the clinician to reduce the patient's work of breathing. Several case series of infants with congenital diaphragmatic hernias (CDH) have shown that NAVA may reduce oxygenation index and mean airway pressures. To date, no clinical trial has compared NAVA to standard methods of mechanical ventilation for babies with CDH. METHODS: The aim of this dual-centre randomised cross-over trial is to compare post-operative NAVA with assist control ventilation (ACV) for infants with CDH. If eligible, infants will be enrolled for a ventilatory support tolerance trial (VSTT) to assess their suitability for randomisation. If clinically stable during the VSTT, infants will be randomised to receive either NAVA or ACV first in a 1:1 ratio for a 4-h period. The oxygenation index, respiratory severity score and cumulative sedative medication use will be measured. DISCUSSION: Retrospective studies comparing NAVA to ACV in neonates with congenital diaphragmatic hernia have shown the ventilatory mode may improve respiratory parameters and benefit neonates. To our knowledge, this is the first prospective cross-over trial comparing NAVA to ACV. TRIAL REGISTRATION: NAN-C was prospectively registered on ClinicalTrials.gov NCT05839340  Registered on May 2023.

Comparing the Efficiency of Infrazygomatic Crest (IZC) Screws and Conventional Method for Anterior Retraction in Patients Undergoing Fixed Orthodontic Treatment for Class 2 Malocclusion: A Prospective Clinical Study.

Introduction In orthodontic treatment for class 2 malocclusion, conventional approaches involve extracting the upper first premolars and using methods like en masse retraction and extra-oral or intra-oral distalization. However, these often result in unintended forces and adverse effects. Contemporary techniques, such as maxillary arch distalization with mini-implants like infrazygomatic crest (IZC) implants, offer superior outcomes. IZC implants provide a safe, flexible, and effective site for implant placement, achieving a remarkable 93.7% success rate. Power arms enable precise control, allowing orthodontists to apply controlled forces for optimal tooth movement. This study aims to compare cephalometric parameters pre and post treatment using IZC/buccal shelf (BS) screws and conventional retraction, assessing the efficiency of IZC screws in maintaining arch length during teeth retraction. Methods In a split-mouth study at Yenepoya Dental College, 40 orthodontic patients aged 18-35 were divided into control (premolar extraction, anterior retraction) and study (third molar removal, IZC screw distalization) groups. The control group used a nitinol spring/E chain for retraction, while the study group employed IZC screw-assisted en masse distalization. Regular reviews and adjustments occurred, with radiographs and study models assessed after six months for cephalometric parameters and arch length. Results A significant difference was found in U1-SN (degree), L1-Apog (in mm), L1-NB (degree), and L1-NB (in mm) of pretreatment records, whereas all other measurements showed statistically similar values between conventional and IZC groups. Improvement was higher with the conventional group when compared with IZC groups in these measurements due to the extraction of the first premolars rather than third molar extraction and distalization. However, the IZC group also showed statistically significant improvement in cephalometric parameters such as U1-SN (degree), L1-Apog (in mm), L1-NB (degree), and L1-NB (in mm). Conclusion  The statistical analysis of radiographic and cast measurements in both the maxilla and mandible demonstrated a significant efficiency of IZC screws in teeth retraction while preserving arch length compared to conventional methods. Nevertheless, to strengthen the findings of our study, additional clinical investigations on IZC screws are warranted.

Sildenafil in Pulmonary Hypertension Associated with Bronchopulmonary Dysplasia: Friend or Foe?

INTRODUCTION: Sildenafil is a phosphodiesterase-5 inhibitor used to treat pulmonary hypertension, although its efficiency remains disputed in the neonatal population. We aimed to assess the clinical use of this drug in extremely premature infants diagnosed with pulmonary hypertension associated to bronchopulmonary dysplasia. STUDY DESIGN: This is a retrospective study of 18 patients born at ≤ 32 weeks gestational age with pulmonary hypertension complicating moderate to severe bronchopulmonary dysplasia, which was diagnosed on echocardiography at 36 weeks corrected gestational age. Median corrected gestational age at starting sildenafil was 48 weeks (range 32-60). In 4 cases there was a period of > 2 weeks between the evidence of moderate-severe pulmonary hypertension and starting sildenafil. In all other cases it was started as soon as the diagnosis was suspected or confirmed. RESULTS: All infants tolerated the use of sildenafil. However, 5 babies (26.31%) died despite ongoing intensive care, and 5 babies (26.31%) died after having care redirected due to severe chronic lung disease (1 due to co-existing neurological abnormality), with on overall mortality of this study of 52.62%. Eight babies (42.1%) survived: 5 continued on sildenafil until hospital discharge, 1 continued on transfer to the paediatric intensive care unit and 2 stopped while inpatients. Upon follow up to 2 years of age, out of the 5 patients who continued upon hospital discharge, 4 stopped at 6, 7, 12 and 18 months respectively, with 1 child being lost to follow up. Two patients (10.52%) restarted sildenafil use later in childhood. Echocardiographic evidence of improvement was noted in 58% (11 cases), with no improvement in 6 cases (32%) and incorrect original diagnosis in 1 case (5%). One infant died less than a week from the initiation of treatment. CONCLUSION: sildenafil use showed no clinical improvement of pulmonary hypertension complicating moderate to severe bronchopulmonary dysplasia in extremely premature infants.

Evaluation of the Effects of Dyslipidemia on Hearing in Patients with Type 2 Diabetes Mellitus.

Modernization has led to change in life style and physical inactivity which are playing a major role in increasing the number of people with diabetes and dyslipidaemia, Different types of hearing loss in diabetic patients have been reported which shows progressive, gradual, bilateral sensorineural loss. The primary aim of the present study is to evaluate the effects of dyslipidemia on hearing in patients with type 2 diabetes mellitus. A comparative study was conducted where patients were divided into 4 groups-Type II diabetes mellitus with dyslipidemia,Type II diabetes mellitus with normal lipid profile, Only Dyslipidemia,Normal subjects. A total of 128 participants were enrolled in the study. The Diabetes patient was determined by the FBS, PPBS and Hba1c levels. Dyslipidemia determined by LDL,HDL,VLDL.Patients with Type 2 diabetes mellitus and dyslipidaemia was evaluated for the presence of hearing loss with the help of PTA. Prevalence of hearing loss among patients with Diabetes and Dyslipidaemia was 65.7%, 40.6% in Type II DM with normal lipid profile patients, 18.75% in patients with dyslipidaemia. Statistically significant association of hearing loss was noted in patients with diabetes mellitus and dyslipidaemia. Although hearing loss is multifactorial, control of the risk factors like dyslipidaemia in diabetes mellitus definitely halt the process of auditory damage. As observed from this study, poor glycaemic control, associated other co-morbidities were contributing factors for hearing loss. Healthy life style with early recognition of these diseases helps in preventing further damage.

Academic Crisis During COVID 19: Online Classes, a Panacea for Imminent Doctors.

Introduction: COVID 19 made a serious impact on many aspects of everyday life. The world saw a paradigm shift in the education system favouring online learning during the constrains of pandemic. Methodology: To assess the attitude of the students towards online learning in subject of ENT, we conducted an observational study among 170 third year MBBS undergraduate students of our institute attending online classes through the student portal of our university website. Results: Our survey revealed students favoured online learning to sustain their academic interest and development during this pandemic. Yet, they perceived many challenges during online learning like lack of face-to-face interactions, lack of socialization, distraction by social media, technology related issues etc. Students also opted for a combined approach of learning in the post pandemic period. Conclusion: This article reflects the challenges faced during online learning and added the innovative methods that can be included to overcome the obstacles of online learning. During this period of COVID, one must embrace the alternative to classroom learning to keep up with one's academic development and can consider an integrated approach of learning after the pandemic.

Role of Neutrophil to Lymphocyte Ratio in Predicting Severity of Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) has been linked to and is associated with increased cardiovascular and cerebrovascular morbidity. Ongoing inflammatory responses play an important role in this association. Systemic inflammation is important in pathophysiology of OSA and its comorbidity. In this study, we aimed to evaluate the role of neutrophil-to-lymphocyte ratio (NLR) in OSA patients and comparing with other well-known inflammatory marker, C-reactive protein (CRP) along with thyroid-stimulating hormone(TSH) and body-mass index(BMI). We conducted a retrospective analysis of 162 patients with OSA and divided them into 2 categories based on apnea-hypopnea index (AHI) (< 30 and > = 30), and recorded their leukocyte profiles, sex, age and body mass index. 80 matched healthy controls were taken. Patients were excluded if they had underlying cancer, chronic inflammatory disease, any systemic infection, uncontrolled hypertension and diabetes mellitus, a known acute coronary syndrome, valvular heart disease, renal or hepatic dysfunction. We found that N/L Ratio in severe OSA patients was significantly higher compared with mild and moderate OSA patients and healthy controls (p < 0.001). CRP levels were not different in all OSA stages (p = 0.595). We noted a significant difference in mean BMI of the two groups. In the wake of increase in prevalence of OSA in a developing country like India coupled with inadequate proportion of sleep labs, NLR is an inexpensive, easy to obtain, widely available marker of inflammation that might in combination with other markers assist in identifying patients with severe OSA.