Assessing the clinical significance of echocardiograms in determining treatment of patent ductus arteriosus in neonates.

BACKGROUND: To evaluate the utility of echocardiogram (ECHO) in detection and treatment of patent ductus arteriosus (PDA) and hemodynamically significant PDA (hsPDA) in preterm neonates. METHODS: This was a retrospective case-control study of all preterm infants born or admitted to the level III Neonatal Intensive Care Unit in McMaster Children's Hospital from January 2009 to January 2013. These cases were further classified into the following sub-groups: group A) hsPDA confirmed on ECHO; and the control, group B) PDA (but not hemodynamically significant) confirmed on ECHO. Patients without an ECHO were excluded from all analyses. The primary outcome was incidence of treatment for PDA. RESULTS: PDA treatment was administered in 83.3% and 11.2% of patients in groups A and B respectively (P < 0.05). Among patients with a hsPDA within group A, 17% did not receive treatment, while 11% of patients with non-hemodynamically significant PDA received treatment for the PDA. Within the cohort of patients who received treatment for a hsPDA, gestational age below 35 weeks as well as murmurs heard on auscultation were both found to be predictors of treatment. CONCLUSION: While the ECHO remains the gold standard for detecting pathological PDA, there is evidence that other traditional clinical measures continue to guide clinical practice and treatment decisions. Further research is required to gain an understanding of how clinical measures and ECHO may be used in conjunction to optimize resource utilization.

Pregnancy-induced hypertension and neonatal outcomes: a systematic review and meta-analysis.

OBJECTIVE: Pregnancy-induced hypertension (PIH) is associated with preterm delivery but its independent impact on neonatal outcomes remains unclear. We sought to systematically review and meta-analyze clinical outcomes of preterm infants <37 weeks' gestation born to mothers with and without PIH. STUDY DESIGN: Medline, Embase, PsychINFO and CINAHL were searched from January 2000 to October 2016. Studies with low-moderate risk of bias reporting neonatal outcomes based on PIH as primary exposure variable were included. Data were extracted independently by two co-authors. RESULTS: PIH was associated with lower mortality (3 studies; adjusted odds ratio (aOR) 0.65; 95% confidence interval (CI) 0.54 to 0.79), lower severe retinopathy of prematurity (ROP) (2 studies; aOR 0.83; 0.72 to 0.96) and lower severe brain injury (2 studies; unadjusted OR (uOR) 0.57; 0.49 to 0.66). No association between PIH and short-term respiratory outcomes, bronchopulmonary dysplasia (BPD) or necrotizing enterocolitis (NEC) was identified. In subgroup analysis among infants <29 weeks' gestation, BPD odds were higher (3 studies; aOR 1.15; 1.06 to 1.26), whereas mortality lower (2 studies; aOR 0.73; 0.69 to 0.77). In subgroup analysis limited to severe PIH, odds of mortality (3 studies; uOR 2.36; 1.07 to 5.22) and invasive ventilation (3 studies; uOR 3.26; 1.11 to 9.61) were higher. In subgroup analysis limited to preeclampsia, odds of BPD (3 studies; uOR 1.21; 95% CI:1.03 to 1.43) and NEC were higher (3 studies; uOR 2.79; 95% CI:1.57 to 4.96). CONCLUSION: PIH was associated with reduced odds of mortality and ROP (all infants), but higher odds for BPD (<29 weeks' gestation). The paradoxical reduction in mortality may be due to survival bias and deserves further exploration in future studies.

Surfactant utilization and short-term outcomes in an era of non-invasive respiratory support in Canadian neonatal intensive care units.

OBJECTIVE: Increased use of non-invasive respiratory support (NRS) in the delivery room management of preterm neonates has resulted in delayed surfactant treatment, yet the short-term effects of this change are unknown. The aim of this study was to comparatively evaluate the use of surfactant and the short-term outcomes prior to and after the implementation of early routine use of NRS. STUDY DESIGN: Eligible infants of <29 weeks gestational age (GA) admitted to a Canadian tertiary neonatal center during two time periods (2005 to 2008 and 2010 to 2013) were included in this retrospective cohort study. Timing of surfactant (prophylactic vs therapeutic) and short-term outcomes were compared between the two groups. Univariate and multivariate regression analysis was performed to determine the adjusted odds ratio (AOR) along with 95% confidence interval (CI) of receiving exogenous surfactant and developing bronchopulmonary dysplasia (BPD) using the later cohort as the reference group. Subgroup analyses were also performed for infants <26 and 26 to 286/7 weeks GA, respectively. RESULTS: A total of 3980 and 5137 infants were included in the first and second time periods, respectively. There was no significant difference in overall surfactant utilization between the two time periods (AOR 1.00, 95% CI 0.89, 1.13). However, between 2005 and 2008, a lower proportion of neonates received therapeutic surfactant compared with the later cohort (47.1% vs 56.9%, P<0.01) but were more likely to receive prophylactic surfactant (52.9% vs 43.1%, P<0.01). BPD overall was significantly higher in the earlier cohort (AOR 1.19, 95% CI 1.07, 1.33), particularly among the <26 weeks gestation subgroup (AOR 1.34, 95% CI 1.08, 1.66). CONCLUSION: Early routine use of NRS did not impact overall surfactant utilization rate, although therapeutic surfactant administration rates were higher with a concomitant decrease in BPD rates.

Bronchopulmonary dysplasia and pulmonary hypertension: a meta-analysis.

OBJECTIVE: Pulmonary hypertension (PH) is a complication of bronchopulmonary dysplasia (BPD) but the true impact of PH in patients with BPD remains unclear. We sought to systematically review and meta-analyze incidence of PH in BPD and compare clinical outcomes of BPD patients with PH to those without PH in preterm infants. STUDY DESIGN: Medline, Embase, PsychINFO and CINAHL were searched from January 2000 through December 2015. Cohort, case-control and randomized studies were included. Case-reports, case-series and letters to editors and studies with high risk of bias were excluded. Study design, inclusion/exclusion criteria, diagnostic criteria for BPD and PH and outcomes were extracted independently by two co-authors. RESULTS: The pooled incidence of PH in patients with BPD (any severity) was 17% (95% confidence interval (CI) 12 to 21; 7 studies) and 24% (95% CI 17 to 30; 9 studies) in moderate-severe BPD. Patients with BPD have higher unadjusted odds of developing PH compared to those without BPD (odds ratio (OR) 3.00; 95% CI 1.18 to 7.66; 4 studies). Patients with BPD and PH were at higher odds of mortality (OR 5.29; 95% CI 2.07 to 13.56; 3 studies) compared with BPD without PH, but there was no significant difference in duration of initial hospitalization, duration of supplemental oxygen requirement or need for home oxygen. No studies included in this review reported on long-term pulmonary or neurodevelopmental outcomes. CONCLUSIONS: PH occurs in one out of 4 to 5 preterm neonates with BPD. Patients with BPD and PH may have higher odds of mortality; however, there is urgent need for high quality studies that control for confounders and provide data on long-term outcomes.

Non-invasive high-frequency ventilation versus bi-phasic continuous positive airway pressure (BP-CPAP) following CPAP failure in infants <1250 g: a pilot randomized controlled trial.

OBJECTIVE: Non-invasive high-frequency ventilation (NIHFV), a relatively new modality, is gaining popularity despite limited data. We sought to evaluate the effectiveness of NIHFV versus bi-phasic continuous positive airway pressure (BP-CPAP) in preterm infants failing CPAP. STUDY DESIGN: Infants with BW<1250 g on CPAP were randomly assigned to NIHFV or BP-CPAP if they met pre-determined criteria for CPAP failure. Infants were eligible for randomization after 72 h age and until 2000 g. Guidelines for adjustment of settings and criteria for failure of assigned mode were implemented. The primary aim was to assess feasibility of a larger trial. In addition, failure of assigned non-invasive respiratory support (NRS) mode, invasive mechanical ventilation (MV) 72 h and 7 days post-randomization, and bronchopulmonary dysplasia (BPD) were assessed. RESULTS: Thirty-nine infants were randomized to NIHFV (N=16) or BP-CPAP (N=23). There were no significant differences in mean (s.d.) postmenstrual age (28.6 (1.5) versus 29.0 (2.3) weeks, P=0.47), mean (s.d.) weight at randomization (965.0 (227.0) versus 958.1 (310.4) g, P=0.94) or other baseline demographics between the groups. Failure of assigned NRS mode was lower with NIHFV (37.5 versus 65.2%, P=0.09), although not statistically significant. There were no differences in rates of invasive MV 72 h and 7 days post-randomization or BPD. CONCLUSION: NIHFV was not superior to BP-CPAP in this pilot study. Effectiveness of NIHFV needs to be proven in larger multi-center, appropriately powered trials before widespread implementation.

Honey on oral mucositis: A Randomized controlled trial.

BACKGROUND AND OBJECTIVE: The main stream of management of head and neck cancer is by radiotherapy and surgery. During radiation therapy in head and neck cancers, oral cavity is directly exposed to high dose radiation which leads to several side effects - oral mucositis being the most distressing one. This study was intended to assess the effects of applying honey on oral mucositis during radiation therapy. MATERIAL AND METHODS: The research design used in this study was Randomized Control Trial with single blinding method in the Radiotherapy Unit of Regional Cancer Centre (RCC), at JIPMER. The study population included a total of 28 patients. Participants in experimental group were given 15ml natural honey for applying on oral mucosa and in control group 15ml plain water were given. Assessment of oral mucosa was done after every 5 doses of radiation therapy using RTOG scale and severity of oral mucositis was assessed. RESULTS: There was a statistically significant difference in degree of oral mucositis between the experimental and control group in week 4, 5 and 6 (p<0.01). During the whole course of study, 9 (64.28 percent) participants in control group developed grade III oral mucositis while only one participant (7.14%) in experimental group developed grade III oral mucositis. CONCLUSION: The study concluded that applying natural honey on oral mucositis was effective among head and neck cancers patients receiving external beam radiation therapy.

Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission.

OBJECTIVE: The objective of this study was to evaluate carbon dioxide (CO2) clearance, delivered pressures and tidal volume (VT) during neonatal nasal intermittent positive pressure ventilation (NIPPV) with two commonly used interfaces. STUDY DESIGN: A neonatal lung model, with either short binasal prongs (SBP) or a small caliber nasal cannula (RAM) interface, was tested over a range of clinically relevant settings. A fixed amount of CO2 was infused and the fraction remaining in the lung 100 s postinfusion was measured. Pressure transmission to the lung and VT was measured at the level of the trachea. RESULT: CO2 elimination was directly proportional to the inspiratory pressure during NIPPV. At peak pressures of 22 to 34 cm H2O, CO2 clearance was greater (P<0.001) with SBP as compared with RAM. Relative to the set ventilator parameters, a substantial pressure dampening effect was documented at the lung level, which was significantly lower with RAM when compared with SBP (2.8% (0.2) versus 11.9% (1.5), P<0.0001). CO2 elimination was dependent on VT and effective despite only a small fraction of physiological VT (maximum delivered VT%: SBP 15.5 (0.7) versus RAM 6.1 (1.4), P<0.0001). CONCLUSION: NIPPV promotes CO2 elimination even at low transmitted airway pressures, but less effective with RAM as compared with SBP. CO2 elimination despite small VT suggests that NIPPV may depend on a non-conventional gas-exchange mechanism.

Bringing back the old: time to reevaluate the high-frequency ventilation strategy.

OBJECTIVE: To examine the role of frequency in high-frequency ventilation (HFV) on carbon-dioxide (CO2) elimination and lung injury, independent of its effect on tidal volume. STUDY DESIGN: An anatomically representative lung model was attached to a mechanical ventilator capable of providing HFV with a constant volume. CO2 was infused directly into the lung, and a commercially available end-tidal CO2 detector was used to determine CO2 elimination. CO2 elimination and amplitude of pressure transmissions were evaluated using frequencies ranging from 5 to 15 Hz. The pressure-volume index (PVI) was described as the product of the volume and pressures delivered to the lung, a surrogate for lung injury. RESULT: The use of increasing frequencies directly correlated with improved CO2 clearance when keeping the tidal volume fixed, expressed as percent CO2 remaining in the lung at 25 s (66.5 (±1.1)%, 50.5 (±0.1)% and 37.8 (±0.3)% at 5, 10 and 15 Hz, respectively, P<0.05). With a fixed tidal volume, there was a decrease in pressure amplitudes transmitted to the lung with a decline in the PVI (53.9 (±2.7) mmHg ml(-1), 41.1 (±0.9) mmHg ml(-1) and 23.4 (±3.6) mmHg ml(-1), at 5, 10 and 15 Hz, respectively, P<0.05). CONCLUSION: Frequency has a direct relationship with CO2 elimination when tidal volume is fixed. Using low delivered tidal volumes and high frequencies may allow for improved ventilation efficacy, while minimizing lung injury.

Differentiation of the human and rat leprosy bacilli by irradiation

The acid-fast property of human leprosy bacilli is significantly altered when exposed for five hours in the sun, two hours in the infra-red or ultra-violet rays or half an the roentgen rays (42r) from a 150 K. V. P. plant. Under similar conditions rat leprosy bacilli are not affected as far as their acid-fast property is concerned