Transitional Hemodynamics in Neonates Born Through Meconium-Stained Amniotic Fluid: A Prospective Observational Study.

Neonates born through meconium-stained amniotic fluid (MSAF) are at increased risk of altered cardiopulmonary transition at birth. There is a paucity of literature evaluating the transitional hemodynamics in these neonates. We aimed to evaluate transitional hemodynamics via echocardiography in neonates born through MSAF, compared to healthy neonates. The primary objective was to assess pulmonary vascular resistance using left pulmonary artery-velocity time integral (LPA-VTI). The secondary objectives were to assess other pulmonary vascular parameters and myocardial function. We enrolled 35 MSAF-born and 35 healthy neonates. Echocardiography was performed at 24 and 48 h of life by a pediatric cardiologist. Echocardiographic parameters were compared between MSAF-born and healthy neonates, and between MSAF-born neonates who developed meconium aspiration syndrome (MAS) and who did not (non-MAS). Among 35 MSAF-born neonates, 14 (40%) were non-vigorous, 18 (51%) required admission to neonatal intensive care unit, 8 (23%) developed MAS, 3 (9%) pulmonary hypertension and 1 (3%) air leak. On echocardiography, LPA-VTI (cm; mean ± SD) was significantly decreased at 24 and 48 h in MSAF-born neonates (14.38 ± 2.48; 15.55 ± 2.48), compared to healthy neonates (16.60 ± 2.14; 17.66 ± 2.71), respectively. Further, LPA-VTI was significantly reduced at 24 and 48 h among MAS (11.81 ± 3.0; 12.43 ± 2.5), compared to non-MAS neonates (15.15 ± 1.72; 16.48 ± 1.55), respectively. Other pulmonary vascular and myocardial function parameters were comparable between the two groups. Pulmonary adaptation was significantly delayed in neonates with MSAF, which was more pronounced in MAS neonates. Further studies should explore the utility of these parameters for early prediction of cardiorespiratory morbidities in this population.

Assessment of Patient Satisfaction and Treatment Outcomes in Digital Smile Design vs. Conventional Smile Design: A Randomized Controlled Trial.

Background: The esthetics of a smile holds significant importance in an individual's self-esteem and overall quality of life. In the realm of cosmetic dentistry, smile design has traditionally relied on conventional methods, but recent advances in technology have introduced digital smile design (DSD) as a promising alternative. Materials and Methods: In this randomized controlled trial, 150 adult patients seeking smile enhancement procedures were enrolled and randomly assigned to one of two groups: the DSD group or the conventional smile design group. The DSD group underwent smile design using digital technology, including intraoral scans, computer-aided design, and 3D simulations. Meanwhile, the conventional smile design group received smile design through traditional methods, involving manual impressions, stone models, and manual wax-ups. Patient satisfaction was measured using a visual analog scale (VAS) ranging from 0 to 100 immediately after the procedure, while treatment outcomes were assessed three months post-procedure by dental professionals using a standardized assessment scale. Results: In terms of patient satisfaction, the DSD group demonstrated a mean score of 85.4 (SD ± 6.2), while the conventional smile design group had a mean score of 79.8 (SD ± 7.1). This suggests that patients in the DSD group reported higher levels of satisfaction with their smile enhancements. Regarding treatment outcomes, 92% of patients in the DSD group exhibited excellent restoration fit, occlusion, and esthetics, whereas 78% of patients in the conventional smile design group achieved the same level of excellence. These findings collectively indicate that digital smile design (DSD) may yield superior patient satisfaction and improved treatment outcomes when compared to conventional smile design methods, particularly with regard to esthetic results and overall patient contentment. Conclusion: In conclusion, the results of this randomized controlled trial emphasize the potential advantages of integrating digital technology into smile design procedures.

Investigating the Long-Term Success and Complication Rates of Zirconia Dental Implants: A Prospective Clinical Study.

This study addresses the durability and complications of zirconia dental implants through a prospective clinical investigation. Zirconia implants are increasingly utilized in dental implantation, and a comprehensive understanding of their long-term performance is essential. Background: Zirconia dental implants have gained attention due to their biocompatibility and aesthetics. However, research on their extended success and complication rates is limited. Materials and Methods: A prospective clinical study involved the placement of 30 zirconia dental implants in patients requiring tooth replacement. The implants were followed up for five years. Success was defined as the implant remaining stable and functional. Complications, including peri-implant mucositis and peri-implantitis, were monitored. Statistical analysis included descriptive statistics, Chi-square test, and P-values were set at P < 0.05. Results: The long-term success rate of zirconia dental implants was found to be 93.3%. Among the 30 implants, only 2 exhibited failure. The most common complication was peri-implant mucositis, occurring in 16.7% of implants. Notably, the incidence of peri-implantitis was limited, observed in 6.7% of implants. Statistical analysis showed significant associations between implant failure and smoking (P = 0.021). Conclusion: Zirconia dental implants demonstrated a high long-term success rate of 93.3% over five years. Peri-implant mucositis was the predominant complication, with a relatively low occurrence of peri-implantitis. The findings underscore the potential of zirconia implants for reliable dental implantation. Addressing modifiable risk factors, such as smoking, could further enhance implant success. Continued research is recommended to validate and expand upon these outcomes.

Efficacy and safety of short- vs. standard-course antibiotics for culture-negative neonatal sepsis: a systematic review and meta-analysis.

OBJECTIVES: To conduct a systematic review and meta-analysis of evidence from randomized controlled trials (RCTs) comparing a short course of antibiotics (2-4 days), to a standard course (5-7 days), for the treatment of culture-negative neonatal sepsis. METHODS: Relevant databases were searched for RCTs comparing short- vs. standard-course of antibiotics for culture-negative sepsis. The primary outcomes were mortality and treatment failure, defined as the reappearance of clinical signs suggestive of sepsis within 7 days of stoppage of antibiotics. Secondary outcomes included neurological impairment, duration of hospital stay, need for oxygen, respiratory support and double-volume exchange transfusion (DVET). RESULTS: Seven RCTs were included in the review with 729 neonates >30 weeks gestational age at birth. No mortality occurred in either of the groups (2 studies; 276 neonates). Treatment failure rates were similar in the short- and standard-course antibiotic groups [7 studies; 729 neonates; risk ratio (RR) = 1.01; 95% confidence interval (CI), 0.55 to 1.86; very low certainty]. The short course of antibiotics resulted in a shorter hospital stay [3 studies; 293 neonates; mean difference (MD), -2.46 days; 95% CI, -3.16 to -1.75]. There was no difference in the need for oxygen supplementation (2 studies; 258 neonates; RR, 1.40; 95% CI, 0.40 to 4.91), any respiratory support (2 studies; 258 neonates; RR, 1.04; 95% CI, 0.92 to 1.17) or DVET (2 studies; 258 neonates; RR, 1.29; 95% CI, 0.56 to 2.95). CONCLUSION: Very-low certainty evidence suggests that a short antibiotic course, compared to a standard course, does not affect treatment failure rates in culture-negative neonatal sepsis. There is a need for well-designed RCTs powered enough to assess critical outcomes such as mortality and neurological sequelae to generate stronger evidence and inform guidelines. PROSPERO REGISTRATION NUMBER: CRD42023437199.

Prolonged antibiotic usage has been associated with increased mortality and morbidity in neonates. The standard practice in culture-negative neonatal sepsis has been to administer antibiotics for 5­7 days, based on expert consensus. In this systematic review, a short course of antibiotics (2­4 days), in comparison to a standard course (5­7 days), did not affect the treatment failure rates in culture-negative neonatal sepsis. However, the certainty of evidence was too low to make robust conclusions. There is a need for well-designed large trials to generate stronger evidence and inform guidelines.

Effect of Splint Application on the Functional Duration of Peripheral Intravenous Cannulation in Neonates: A Systematic Review and Meta-analysis.

BACKGROUND: The application of splints is one of the most used methods to prolong the life span of peripheral intravenous cannulation (PIVC). OBJECTIVE: To assess the effect of splint application on the functional duration of PIVC in neonates. METHODS: This systematic review and meta-analysis identified, appraised, and synthesized available evidence from randomized and quasi-randomized controlled trials (RCT) related to the effects of splint application compared to no splinting on the functional duration of PIVC and its associated complications in term and preterm neonates. Data were pooled using RevMan 5.4. The quality of evidence for predefined outcomes was analyzed by GRADE. RESULTS: Available evidence (5 RCTs, 826 neonates) showed a significantly lesser functional duration of PIVC in the splint group compared to no-splint [Mean Difference (MD) 95% Confidence Interval (CI) -3.07 (-5.63, -0.51); Low Certainty of Evidence (CoE)]. On gestation-based subgroup analysis, PIVC duration remained significantly lesser in the splint group in preterm neonates [MD (95% CI), -5.09 (-9.53, -0.65), 2 studies, n = 220; Low CoE], whereas it was comparable in the term neonates [MD (95% CI), 3.92 (-4.27, 12.10), 2 studies, n = 89; Very low CoE]. The overall complications were comparable between the groups [Risk Ratio (95% CI), 1.02 (1.00, 1.05), 5 studies, n = 826; Very low CoE]. CONCLUSION: Based on the very low to low CoE found in this systematic review, it is not possible to recommend or refute splint application in neonates. Further well-designed RCTs are needed.

T-Piece resuscitator versus self-inflating bag for delivery room resuscitation in preterm neonates: a randomized controlled trial.

The establishment of adequate ventilation is the cornerstone of neonatal resuscitation in the delivery room (DR). This parallel-group, accessor-blinded randomized controlled trial compared the changes in peripheral oxygen saturation (SpO2), heart rate (HR), and cerebral regional oxygen saturation (crSO2) with the use of a T-piece resuscitator (TPR) versus self-inflating bag (SIB) as a mode of providing positive pressure ventilation (PPV) during DR resuscitation in preterm neonates. Seventy-two preterm neonates were randomly allocated to receive PPV with TPR (n = 36) or SIB (n = 36). The primary outcome was SpO2 (%) at 5 min. The secondary outcomes included the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, fractional-inspired oxygen (FiO2) requirement, minute-specific SpO2, HR and FiO2 trends for the first 5 min of life, need for DR-intubation, crSO2, need and duration of respiratory support, and other in-hospital morbidities. Mean SpO2 at 5 min was 74.5 ± 17.8% and 69.4 ± 22.4%, in TPR and SIB groups, respectively [Mean difference, 95% Confidence Interval 5.08 (-4.41, 14.58); p = 0.289]. No difference was observed in the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, the requirement of FiO2, DR-intubation, and the need and duration of respiratory support. There was no significant difference in the minute-specific SpO2, HR, and FiO2 requirements for the first 5 min. CrSO2 (%) at one hour was lower by 5% in the TPR group compared to SIB; p = 0.03. Other complications were comparable. CONCLUSIONS: TPR and SIB resulted in comparable SpO2 at 5 min along with similar minute-specific SpO2, HR, and FiO2 trends. CLINICAL TRIAL REGISTRATION: Clinical trial registry of India, Registration no: CTRI/2021/10/037384, Registered prospectively on: 20/10/2021, https://ctri.icmr.org.in/ . WHAT IS KNOWN: • Compared to self-inflating bags (SIB), T-piece resuscitators (TPR) provide more consistent inflation pressure and tidal volume as shown in animal and bench studies. • There is no strong recommendation for one device over the other in view of low certainty evidence. WHAT IS NEW: • TPR and SIB resulted in comparable peripheral oxygen saturation (SpO2) at 5 min along with similar minute-specific SpO2, heart rate, and fractional-inspired oxygen requirement trends. • Short-term complications and mortality rates were comparable with both devices.

Neonatal Pain Response to Various Heel Prick Devices: A Randomized Controlled Trial.

BACKGROUND: Heel prick is a commonly performed painful intervention in neonates. Though different devices are available, there is a need to compare the procedural pain response elicited by them. OBJECTIVE: To compare the neonatal pain response to three different heel prick devices; automatic lancet, manual lancet, and 26-gauge (G) hypodermic needle. DESIGN: Parallel-group three-arm randomized controlled trial. PARTICIPANTS: Clinically stable neonates of gestational age >28 weeks and birth weight >800 g undergoing heel prick for estimation of random blood sugar. METHODS: One hundred and eighty neonates were randomized to automatic lancet (n=59), manual lancet (n=59), or needle (n=62) groups between March, 2021 and August, 2022. The primary outcome was the premature infant pain profile-revised (PIPP-R) score. Secondary outcomes were post-intervention cerebral regional oxygen saturation (CrSO2), changes in CrSO2 (DCrSO2), the time for CrSO2 normalization using near-infrared spectroscopy, duration of audible cry, and the number of squeezes and pricks needed. Intention-to-treat analysis was done. RESULTS: Median (IQR) of PIPP-R scores were comparable in the automatic lancet [6 (4, 7.5)], manual lancet [5.5 (3.5, 8)], and needle [6 (3-9.6)] groups; P=0.59. No difference was observed in post-intervention CrSO2, DCrSO2, and the number of pricks. However, the time required for CrSO2 normalization and the number of squeezes were significantly higher with the needle. CONCLUSION: All three devices induced similar pain responses to heel prick in neonates; though, the number of squeezes needed was higher with the needle.

Functional Duration of Peripheral Intravenous Cannula in Neonates with or without Splint: A Randomized Controlled Trial.

OBJECTIVES: To determine the effect of splint on the functional duration of peripheral intravenous cannula (PIVC) in neonates. METHODS: The trial was prospectively registered with the Clinical Trial Registry of India (CTRI/2021/09/036337). One-hundred-fifty cannulations in 71 neonates were randomized to splint (n = 75) and no-splint (n = 75) groups, respectively. The median (interquartile range, IQR) functional duration of PIVC was calculated from the time of PIVC insertion till removal due to the development of signs of PIVC failure or treatment completion. Kaplan-Meier survival analysis was used to compute the time to complication of PIVC. Complications related to PIVC were noted and multivariate Cox-proportion hazard analysis was done to find the predictors associated with PIVC failure. RESULTS: Median (IQR) functional duration of PIVC in the splint and the no-splint group was 28 (23-48) and 30 (25-48) h, respectively (p = 0.477). PIVC duration was higher in the splint group in term neonates and the no-splint group in preterm neonates; however, the differences were not statistically significant. No difference was observed in continuous vs. intermittent infusion subgroups. Time to complication development was also comparable between the groups. CONCLUSIONS: Splint application did not affect functional PIVC duration and its related complications in neonates.

Proud Syndrome: A Rare Cause of Corpus Callosum Agenesis.

Agenesis of the corpus callosum (ACC) is one of the most common congenital brain anomalies with variable associations and outcomes. The incidence of ACC varies from 1.8 per 10,000 live births in normal children to as high as 600 per 10,000 in children with neurodevelopmental problems. Here, we report the case of a female neonate delivered in our institute at term gestation to a gravida 4 mother with partial ACC. The neonate was antenatally diagnosed with ACC. The mother had a previous fetus with a supratentorial cyst that was medically terminated. The neonate had a normal clinical examination, but the ultrasound of the cranium suggested ACC. Given the significant family history, a clinical exome sequencing test revealed a pathogenic frameshift mutation in the ARX gene that causes Proud syndrome. We discuss the relevant points in the diagnosis, workup, and prognosis of ACC through this case. This case highlights the importance of antenatal assessment for timely amniocentesis and a genetic diagnosis to guide the parental decision for continuation of the pregnancy, level 2 scans to detect associated anomalies, and postnatal assessment to determine the cause and prognosis of a neonate with ACC.

Effects of umbilical cord milking versus delayed cord clamping on systemic blood flow in intrauterine growth-restricted neonates: A randomized controlled trial.

Recommendations for umbilical cord management in intrauterine growth-restricted (IUGR) neonates are lacking. The present randomized controlled trial compared hemodynamic effects of umbilical cord milking (UCM) with delayed cord clamping (DCC) in IUGR neonates > 28 weeks of gestation, not requiring resuscitation. One hundred seventy IUGR neonates were randomly allocated to intact UCM (4 times squeezing of 20 cm intact cord; n = 85) or DCC (cord clamping after 60 s; n = 85) immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24 ± 2 h. Secondary outcomes assessed were anterior cerebral artery (ACA) and superior mesenteric artery (SMA) blood flow indices, right ventricular output (RVO), regional cerebral oxygen saturation (CrSO2) and venous hematocrit at 24 ± 2 h, peak total serum bilirubin (TSB), incidences of in-hospital complications, need and duration of respiratory support, and hospital stay. SVC flow was significantly higher in UCM compared to DCC (111.95 ± 33.54 and 99.49 ± 31.96 mL/kg/min, in UCM and DCC groups, respectively; p < 0.05). RVO and ACA/SMA blood flow indices were comparable whereas CrSO2 was significantly higher in UCM group. Incidences of polycythemia and jaundice requiring phototherapy were similar despite significantly higher venous hematocrit and peak TSB in UCM group. The need for non-invasive respiratory support was significantly higher in UCM group though the need and duration of mechanical ventilation and other outcomes were comparable. CONCLUSIONS:  UCM significantly increases SVC flow, venous hematocrit, and CrSO2 compared to DCC in IUGR neonates without any difference in other hemodynamic parameters and incidences of polycythemia and jaundice requiring phototherapy; however, the need for non-invasive respiratory support was higher with UCM. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/03/031864). WHAT IS KNOWN: • Umbilical cord milking (UCM) increases superior vena cava blood flow (SVC flow) and hematocrit without increasing the risk of symptomatic polycythemia and jaundice requiring phototherapy in preterm neonates compared to delayed cord clamping (DCC). • An association between UCM and intraventricular hemorrhage in preterm neonates < 28 weeks of gestation is still being investigated. WHAT IS NEW: • Placental transfusion by UCM compared to DCC increases SVC flow, regional cerebral oxygenation, and hematocrit without increasing the incidence of symptomatic polycythemia and jaundice requiring phototherapy in intrauterine growth-restricted neonates. • UCM also increases the need for non-invasive respiratory support compared to DCC.

Effects of delayed cord clamping at different time intervals in late preterm and term neonates: a randomized controlled trial.

Delayed cord clamping (DCC) at delivery has well-recognized benefits; however, current scientific guidelines lack uniformity in its definition. This parallel-group, three-arm assessor-blinded randomized controlled trial compared the effects of three different timings of DCC at 30, 60, and 120 s on venous hematocrit and serum ferritin levels in late preterm and term neonates not requiring resuscitation. Eligible newborns (n = 204) were randomized to DCC 30 (n = 65), DCC 60 (n = 70), and DCC 120 (n = 69) groups immediately after delivery. The primary outcome variable was venous hematocrit at 24 ± 2 h. Secondary outcome variables were respiratory support, axillary temperature, vital parameters, incidences of polycythemia, neonatal hyperbilirubinemia (NNH), need and duration of phototherapy, and postpartum hemorrhage (PPH). Additionally, serum ferritin levels, the incidence of iron deficiency, exclusive breastfeeding (EBF) rate, and anthropometric parameters were assessed during post-discharge follow-up at 12 ± 2 weeks. Over one-third of the included mothers were anemic. DCC 120 was associated with a significant increase in the mean hematocrit by 2%, incidence of polycythemia, and duration of phototherapy, compared to DCC30 and DCC60; though the incidence of NNH and need for phototherapy was similar. No other serious neonatal or maternal adverse events including PPH were observed. No significant difference was documented in serum ferritin, incidences of iron deficiency, and growth parameters at 3 months even in the presence of a high EBF rate.   Conclusion: The standard recommendation of DCC at 30-60 s may be considered a safe and effective intervention in the busy settings of low-middle-income countries with a high prevalence of maternal anemia.   Trial registration: Clinical trial registry of India (CTRI/2021/10/037070). What is Known: • The benefits of delayed cord clamping (DCC) makes it an increasingly well-accepted practice in the delivery room. • However, uncertainty continues regarding the optimal timing of clamping; this may be of concern both in the neonate and the mother. What is New: • DCC at 120 s led to higher hematocrit, polycythemia and longer duration of phototherapy, without any difference in serum ferritin, and incidence of iron deficiency. • DCC at 30-60 s may be considered a safe and effective intervention in LMICs.

Point-of-Care Serum Amyloid A as a Diagnostic Marker for Neonatal Sepsis.

OBJECTIVES: To evaluate diagnostic accuracy of point-of-care Serum Amyloid A (POC-SAA) and its comparison with procalcitonin for diagnosis of neonatal sepsis. METHODS: The present diagnostic accuracy study consecutively recruited neonates with suspected sepsis. Blood samples for sepsis screen, culture, high sensitivity C-reactive protein (CRP) (hs-CRP, as a part of sepsis screen), procalcitonin and POC-SAA were collected before starting antibiotics. The optimum cut-off level of biomarkers (POC-SAA and procalcitonin) was determined by receiver-operating-characteristics curve (ROC) analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of POC-SAA and procalcitonin were derived for 'clinical sepsis (neonates with suspected sepsis and either positive sepsis screen and/or blood culture)' and 'culture positive sepsis' (neonates with suspected sepsis and positive blood culture). RESULTS: Seventy-four neonates with mean±SD gestational age of 32.8±3.7 wk were evaluated for suspected sepsis, of which the proportion of 'clinical sepsis' and 'culture positive sepsis' was 37.8% had 16.2%, respectively. At a cut-off of 25.4 mg/L, POC-SAA had sensitivity, specificity, PPV and NPV of 53.6%, 80.4%, 62.5% and 74.0%, respectively for diagnosis of clinical sepsis. The sensitivity, specificity, PPV and NPV of POC-SAA for detection of culture positive sepsis were 83.3%, 61.3%, 29.4% and 95.0%, respectively at a cut-off of 10.3 mg/L. There was no significant difference in the diagnostic accuracy of biomarkers for detection of culture positive sepsis (area under the curve, AUC of POC-SAA vs. procalcitonin vs. hs-CRP: 0.72 vs. 0.85 vs. 0.85; p = 0.21). CONCLUSIONS: POC-SAA is comparable to procalcitonin and hs-CRP for diagnosis of neonatal sepsis.

Impact of Delivery Room Gastric Lavage on Exclusive Breastfeeding Rates Among Neonates Born Through Meconium-Stained Amniotic Fluid: A Randomized Controlled Trial.

BACKGROUND: Delivery-room gastric lavage reduces feeding intolerance and respiratory distress in neonates born through meconium-stained amniotic fluid (MSAF). OBJECTIVES: To evaluate the effects of gastric lavage on exclusive breastfeeding and skin-to-skin contact in neonates delivered through MSAF. DESIGN: Randomized controlled trial. PARTICIPANTS: 110 late preterm and term neonates delivered through MSAF not requiring resuscitation beyond initial steps. METHODS: Participants randomized into gastric lavage (GL) (n=55) and no-GL (n=55) groups. The primary outcome was the rate of exclusive breastfeeding at 72±12 hours of life. Secondary outcomes were time to initiate breastfeeding and establish exclusive breastfeeding, rate of exclusive breastfeeding at discharge, time to initiate skin-to-skin contact and its duration, rates of respiratory distress, feeding intolerance, and the procedure-related complications of gastric lavage monitored by pulse oximetry and videography. RESULTS: Both the groups were similar in baseline characteristics. 49 (89.1%) neonates in GL group could achieve exclusive breast-feeding at 72 hours compared to 48 (87.3%) in no-GL group [RR (95% CI) 1.02 (0.89-1.17); P=0.768]. Initiation of skin-to-skin contact was significantly delayed and the total duration was significantly less in GL group compared to no-GL group. No difference in respi-ratory distress and feeding intolerance was observed. Procedure-related complications included retching, vomiting, and mild desaturation. CONCLUSION: Gastric lavage did not help to establish exclusive breastfeeding, delayed the initiation of skin-to-skin contact in delivery room and reduced its total duration. Moreover, the procedure of gastric lavage was associated with neonatal discomfort.

Infracardiac obstructive total anomalous pulmonary venous return with ventricular septal defect: a rare anomaly.

The infracardiac variant of total anomalous pulmonary venous return occurs only rarely and is frequently obstructive in nature, thereby presenting in the early days of life [1]. An atrial septal defect is present in most cases and is necessary for survival, but a ventricular septal defect is extremely rare; only a few cases have been reported. Surgery is the only treatment option but carries a high risk of morbidity and mortality.