Lactobacillus GG for treatment of acute childhood diarrhoea: an open labelled, randomized controlled trial

BACKGROUND & OBJECTIVES

Randomized controlled trials in developed countries have reported benefits of Lactobacillus GG (LGG) in the treatment of acute watery diarrhoea, but there is paucity of such data from India. The study was aimed to evaluate the efficacy and safety of Lactobacillus GG in the treatment of acute diarrhoea in children from a semi-urban city in north India.

METHODS

In this open labelled, randomized controlled trial 2000 children with acute watery diarrhoea, aged between 6 months to 5 years visiting outpatient department and emergency room of a teaching hospital in north India were enrolled. The children were randomized into receiving either Lactobacillus GG in dose of 10 billion cfu/day for five days or no probiotic medication in addition to standard WHO management of diarrhoea. Primary outcomes were duration of diarrhoea and time to change in consistency of stools.

RESULTS

Median (inter quartile range) duration of diarrhoea was significantly shorter in children in LGG group [60 (54-72) h vs. 78 (72-90) h; P<0.001]. Also, there was faster improvement in stool consistency in children receiving Lactobacillus GG than control group [36 (30-36) h vs. 42 (36-48) h; P<0.001]. There was significant reduction in average number of stools per day in LGG group (P<0.001) compared to the control group. These benefits were seen irrespective of rotavirus positivity in stool tests.

INTERPRETATION & CONCLUSIONS

Our results showed that the use of Lactobacillus GG in children with acute diarrhoea resulted in shorter duration and faster improvement in stool consistency as compared to the control group.

Ochratoxin A induces cytotoxicity, DNA damage and apoptosis in rat hepatocyte primary cell culture at nanomolar concentration

Ochratoxin A (OTA), a mycotoxin produced by several species of Aspergillus and Penicillum, is widely found as a contaminant of food. OTA exhibits a wide range of toxic activities, including nephro- and hepatotoxicity. Although the mechanisms of its genotoxicity and carcinogenicity have been studied before, many controversial results have been published. In addition, the studies were mostly conducted with kidney cells. Therefore, the present study used a primary culture of Wistar rat hepatocytes incubated with increasing concentrations of OTA (2.0-6.0 nanomolar). OTA treatment showed dose-dependent cytotoxicity and DNA damage. Further, flow cytometric analysis of hepatocytes showed dose-dependent apoptosis, suggesting that OTA-induced hepatotoxicity is, may be partly, mediated by apoptosis. Vascular endothelial growth factor gene, a potent pro-angiogenic in hepatocellular carcinoma and responsible for hepatocyte regeneration, did not show any change with OTA treatment, as analysed by reverse transcription polymerase chain reaction. Thus, the present data indicated OTA-induced rat hepatotoxicity in vitro at nanomolar concentration, which inferred a major possible target other than kidney cells.

Randomized controlled trial of topical EMLA and breastfeeding for reducing pain during wDPT vaccination

The primary objective was to evaluate the analgesic effect of a eutectic mixture of local anesthetics (EMLA) during whole cell DPT vaccination. The secondary objective was to evaluate if the analgesic effect of EMLA was synergistic to breastfeeding. A randomized, placebo-controlled trial was done to include infants of up to 3 months of age who came for their first DPT vaccination. The outcome variables were duration of cry, latency of onset of cry, and Modified Facial Coding Score. Thirty babies were enrolled in each of three groups. The groups did not differ significantly in baseline characteristics. Median (interquartile range) of duration of cry was least [34.6 (24.1-72.2) s] in babies receiving EMLA cream with breastfeeding (EB group), followed by 94.2 (46.1-180) s in babies receiving EMLA cream with oral distilled water (EW group), as compared to 180.0 (180-180) s in babies receiving placebo cream with oral distilled water (PCW group) (p < 0.05). Mean (SD) of latency of cry was significantly greater in EB group [2.4 (1.14) s] and EW group [1.9 (0.62) s] as compared to babies in PCW group [1.5 (0.47) s] (p < 0.05), but the difference between EB and EW groups was not significant. Modified Facial Coding Score was significantly lower in EB group as compared to the other groups (p < 0.05).

CONCLUSIONS

Topical EMLA is effective in reducing pain and has a synergistic effect in analgesia when combined with breastfeeding during vaccination in infants.

Effect of umbilical cord milking in term and near term infants: randomized control trial

OBJECTIVE

The objective of the study was to investigate the effect of umbilical cord milking as compared with early cord clamping on hematological parameters at 6 weeks of age among term and near term neonates.

STUDY DESIGN

This was a randomized control trial. Eligible neonates (>35 weeks' gestation) were randomized in intervention and control groups (100 each). Neonates of both groups got early cord clamping (within 30 seconds). The cord of the experimental group was milked after cutting and clamping at 25 cm from the umbilicus, whereas in control group cord was clamped near (2-3 cm) the umbilicus and not milked. Both groups got similar routine care. Unpaired Student t and Fisher exact tests were used for statistical analysis.

RESULTS

Baseline characteristics were comparable in the 2 groups. Mean hemoglobin (Hgb) (11.9 [1.5] g/dL and mean serum ferritin 355.9 [182.6] μg/L) were significantly higher in the intervention group as compared with the control group (10.8 [0.9] g/dL and 177.5 [135.8] μg/L), respectively, at 6 weeks of age. The mean Hgb and hematocrit at 12 hours and 48 hours was significantly higher in intervention group (P = .0001). The mean blood pressure at 30 minutes, 12 hours, and 48 hours after birth was significantly higher but within normal range. No significant difference was observed in the heart rate, respiratory rate, polycythemia, serum bilirubin, and need of phototherapy in the 2 groups.

CONCLUSION

Umbilical cord milking is a safe procedure and it improved Hgb and iron status at 6 weeks of life among term and near term neonates.

Sequence, structure, and evolution of cellulases in glycoside hydrolase family 48

Currently, the cost of cellulase enzymes remains a key economic impediment to commercialization of biofuels. Enzymes from glycoside hydrolase family 48 (GH48) are a critical component of numerous natural lignocellulose-degrading systems. Although computational mining of large genomic data sets is a promising new approach for identifying novel cellulolytic activities, current computational methods are unable to distinguish between cellulases and enzymes with different substrate specificities that belong to the same protein family. We show that by using a robust computational approach supported by experimental studies, cellulases and non-cellulases can be effectively identified within a given protein family. Phylogenetic analysis of GH48 showed non-monophyletic distribution, an indication of horizontal gene transfer. Enzymatic function of GH48 proteins coded by horizontally transferred genes was verified experimentally, which confirmed that these proteins are cellulases. Computational and structural studies of GH48 enzymes identified structural elements that define cellulases and can be used to computationally distinguish them from non-cellulases. We propose that the structural element that can be used for in silico discrimination between cellulases and non-cellulases belonging to GH48 is an ω-loop located on the surface of the molecule and characterized by highly conserved rare amino acids. These markers were used to screen metagenomics data for "true" cellulases.

K/B×N serum transfer arthritis is delayed and less severe in leukaemia inhibitory factor (LIF)-deficient mice

This study is investigating the role of leukaemia inhibitory factor (LIF) in the development of inflammation and joint damage in the mouse K/B×N serum transfer arthritis model. LIF knock-out (LIF(-/-)) mice were generated by mating heterozygote females (LIF(+/-)) with heterozygote males. Arthritis was induced in 8-20-week-old LIF knock-out mice (LIF(-/-)) by intraperitoneal injection of pooled K/B×N sera (50 µl) on days 0 and 2. Clinical disease was scored daily for 6 days. Safranin-O and haematoxylin-stained sections were scored for synovitis, joint space exudate, cartilage degradation and bone damage. RNA was extracted from ankle joints and used to investigate gene expression levels of tumour necrosis factor (TNF)-α, interleukin (IL)-1, LIF, LIF receptor, oncostatin M (OSM), OSM receptor, IL-6 and their common receptor subunit gp130 by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). The results show that wild-type mice developed severe clinically overt polyarthritis. In contrast, LIF(-/-) mice showed a more than 50% reduction in clinical arthritis severity. Significantly lower histological scores were observed in LIF(-/-) mice compared to wild-type disease controls. LIF(-/-) mice had histopathological scores that were similar to normal healthy mice. IL-6 subfamily cytokine and receptor subunit expression remained unchanged. The expression levels for IL-6 were reduced significantly in all the diseased mice, whether wild-type or LIF(-/-) mice (P < 0·001), compared to healthy wild-type mice. We conclude that LIF contributes to the development of disease in the K/B×N serum transfer model of arthritis. These results provide further evidence for the role of LIF in inflammation and cartilage bone resorption and provide impetus to test the effects of LIF blockade as a therapeutic strategy in rheumatoid arthritis.

Phase velocity and particle injection in a self-modulated proton-driven plasma wakefield accelerator

It is demonstrated that the performance of the self-modulated proton driver plasma wakefield accelerator is strongly affected by the reduced phase velocity of the plasma wave. Using analytical theory and particle-in-cell simulations, we show that the reduction is largest during the linear stage of self-modulation. As the instability nonlinearly saturates, the phase velocity approaches that of the driver. The deleterious effects of the wake's dynamics on the maximum energy gain of accelerated electrons can be avoided using side-injections of electrons, or by controlling the wake's phase velocity by smooth plasma density gradients.

Immunomodulatory efficacy of nisin--a bacterial lantibiotic peptide

Nisin is a peptide bacteriocin, grouped under the category of lantibiotics. It is naturally produced by Lactococcus lactis to eliminate other competing gram-positive bacteria from its vicinity. Moreover under certain conditions it is reported to be effective against a broad range of gram-negative bacteria as well. Thus, it has been widely used as a safe food preservative especially in the dairy industry. Because of its wide-scale consumption, its effect on eukaryotic cells should be of great concern. Here we examine the immunomodulatory efficacy of nisin in vitro. MTT-based cytotoxicity assay demonstrated nisin's cytotoxicity on human T-cell lymphoma Jurkat cells, Molt-4 cells and freshly cultured human lymphocytes at over 200 µM concentration (IC(50) 225 µM). The cell death mechanism induced by nisin in all these lymphocyte types was independent of oligonucleosomal DNA fragmentation, as analyzed by agarose gel electrophoresis and comet assay. Additionally, scanning electron microscope and fluorescence microscopy demonstrated the ability of nisin to activate human PMNs in vitro. Nisin-activated neutrophils extruded intact nuclear chromatin to form NETs, well known for neutralization of virulence factors and extermination of bacterial pathogens. Nisin's presence also elevated neutrophil intracellular superoxide levels, normally produced by activated NADPH oxidase and prerequisite to NET formation. These nisin-induced responses in cellular representatives of two separate branches of human immune system-adaptive and innate-although leading to cell death, did not include DNA fragmentation. From these findings, we propose that nisin might trigger similar AICD mechanisms in lymphocytes and neutrophils, different from conventional apoptosis which involves DNA fragmentation.

Ferritin concentrations in synovial fluid are higher in osteoarthritis patients with HFE gene mutations (C282Y or H63D)

OBJECTIVES

In view of the clinical similarities between polyarticular osteoarthritis (POA) with metacarpophalangeal (MCP) joint involvement and the arthropathy that occurs in hereditary haemochromatosis (HH), it was hypothesized that osteochondral damage in both disorders may be due to localized iron overload. Accordingly, it was predicted that the concentration of ferritin in synovial fluid (SF) would be higher in OA patients with HFE gene mutations than in HFE wild-type (wt) OA patients. The aim of this study was to test this proposition.

METHODS

Sequential patients with physician-diagnosed OA and, for comparison, diverse inflammatory diseases of the joints, who required diagnostic or therapeutic arthrocentesis, were studied. Participants underwent HFE genotyping. SF samples were assayed for ferritin and also for selected cytokines and matrix metalloproteinases (MMPs).

RESULTS

Seventy-three patients with diverse rheumatic disorders were recruited. Of the 29 patients who had knee OA, 15 were wt and 14 were heterozygous for HFE mutations (C282Y or H63D). Mean SF ferritin concentrations in the wt and heterozygous OA groups were 273 and 655 ng/mL, respectively (p = 0.0146).

CONCLUSIONS

A predicted difference in SF ferritin concentrations in patients with knee OA was confirmed. Concentrations of ferritin in the SF were found to be two- to threefold higher in knee OA patients with HFE gene mutations compared to wt patients. This finding is consistent with the possibility that, in OA patients with HFE gene mutations, localized iron overload may contribute either directly or indirectly to osteochondral damage, possibly in a similar way to that which occurs in the arthropathy that complicates HH.

Lipid profile in high risk children aged 2-10 years

A case-control study was conducted to study the Lipid profile of high risk children (age 2-10 years). There was a significant elevation of total cholesterol (P<0.001) and LDL (P< 0.001). Early dietary and lifestyle modifications can prevent this cascade.

Sclerotherapy for hydrocele revisited: a prospective randomised study

PURPOSE

A prospective randomised trial to study the efficacy and safety of hydrocele sclerotherapy with phenol and polidocanol.

METHODS

Eighty-six patients with unilateral primary vaginal hydroceles were randomised into three groups: group 1 (phenol sclerotherapy) - 29 patients, group 2 (polidocanol sclerotherapy) - 29 patients and group 3 (operative treatment) - 28 patients. Sclerotherapy was performed on outpatient basis using either 5-10 ml of 5% phenol or 2-4 ml of 1% polidocanol, while patients in group 3 underwent surgical repair of hydrocele (Jaboulay's procedure). Statistical analysis was performed using ANOVA.

RESULTS

The cure rates in group 1, 2 and 3 were 96.5%, 51.7% and 100%, respectively. The pain scores (visual analogue scale) in group 1, 2 and 3 at 1 week and 1 month were 14.5 and 1.8; 10.1 and 1.3; 64.0 and 10.6, respectively. There was significant difference among the three groups in mean hospital stay (1.8, 1.5 and 9.7 hours, respectively) and time to work resumption (1.3, 1.1 and 12.7 days, respectively). Statistically significant differences in pain scores and complications were observed between sclerotherapy and operative groups.

CONCLUSION

Five percent phenol is a better sclerosant than 1% polidocanol and is as efficacious as operative treatment, with lesser morbidity and similar safety profile.

Characterization of a new isolate of Pseudomonas fluorescens strain Psd as a potential biocontrol agent

AIMS

Evaluation of a new isolate of Pseudomonas fluorescens for its biocontrol properties.

METHODS AND RESULTS

Strain Psd identified as Ps. fluorescens, produces secondary metabolites that are toxic to some plant-pathogenic fungi. Inhibition of fungal growth of Fusarium oxysporum and Verticillium dahliae in the presence of bacterial culture filtrate provided the first clue to its biocontrol properties. In order to determine the basis for antifungal properties, antibiotics were extracted and analysed by TLC. Both pyrrolnitrin and phenazines could be detected in the culture of Psd. Presence of response regulator gene gacA of the two component regulatory system (GacS/GacA) was established by PCR amplification and sequencing. Sequence comparison of gacA justified the taxonomic position of this strain among the known members of Pseudomonadaceae. Synthesis of other compounds like toxic lipodepsipeptide, siderophores, and HCN was also confirmed by appropriate biochemical tests.

CONCLUSION

Characterization of strain Psd by various biochemical/plate tests followed by chromatographic identification of antibiotics, demonstrates its multifunctional biocontrol property. Response regulator gene gacA provides an additional genetic marker for the phylogenetic studies.

SIGNIFICANCE AND IMPACT OF THE STUDY

Ps. fluorescens strain Psd with its multifunctional biocontrol property can be used to bioprotect the crop plants from phytopathogens.

Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy

BACKGROUND

Laparoscopic management of nonobstetric acute abdominal pain during pregnancy remains controversial. A gestational age of 26 to 28 weeks has been considered the upper limit for laparoscopy by some authors. A case series of nonobstetric surgery in advanced pregnancy is reported.

METHODS

Third-trimester patients who underwent surgery between 1997 and 2006 were reviewed.

RESULTS

Laparoscopic surgery was performed for nonobstetric emergencies during the third trimester for 11 patients. Four patients underwent open surgery. The laparoscopic surgery group included five cholecystectomies, four appendectomies, and two adenexal surgeries. The laparoscopic surgery procedure was successfully completed for 10 patients. Of these 10 patients, 9 had no complications and went on to deliver a healthy term infant. One patient went into preterm labor after a laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis and delivered a viable infant at 34 weeks. Another patient at 29 weeks of gestation underwent a diagnostic laparoscopy for abdominal pain. Adenexal torsion of a large multicystic ovarian mass led to a laparotomy (obstetrician preference) and right salpingo-oophrectomy. Her postoperative course was complicated by an episode of sudden syncope, hypotension, and fetal distress on postoperative day 3. An emergent laparotomy showed hemoperitoneum attributable to bleeding from the ovarian pedicle. A cesarean section delivery of a preterm infant requiring neonatal resuscitation was performed. The open surgery group included four patients. Two of the patients underwent appendectomies at 35 and 33 weeks, respectively, followed by a term delivery. The remaining two patients underwent emergent colectomies with a cesarean section delivery at 31 and 38 weeks, respectively.

CONCLUSIONS

This study demonstrated that laparoscopic surgery in the third trimester of pregnancy is feasible and can be performed safely with an acceptable risk to the fetus and the mother. Access to the pregnant abdomen is easily obtained. Space generally is not a problem, and there is minimal uterine manipulation.

Clinical profile and natural history of children with HIV infection

OBJECTIVE

As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.

METHODS

We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.

RESULTS

109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months-180 months). Eighty one (74.3%) children acquired the infection vertically. Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.

CONCLUSION

Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.

Antiretroviral therapy in HIV-1 infected children

Highly active antiretroviral therapy is beyond reach of most HIV-infected children in developing countries. There is paucity of data on more affordable regimens such as ones based on nevirapine and 2 nucleoside reverse transcriptase inhibitors. We report our experience with the use of antiretroviral therapy in children with HIV-1 infection at a tertiary care hospital in north India. The study subjects were HIV-1 infected children, who were receiving 3-drug antiretroviral therapy for a period of three or more months. The children were regularly followed up for any complications, changes in anthropometry, and changes in CD4 counts. The mean age of children at diagnosis (n=26; 22 boys) was 68.5 +- 33.4 months. These children were followed up for a mean of 19.7 +- 18.7 months. Twenty four children received nevirapine based regimen. There was statistically significant improvement in weight for height and body mass index on follow up. The mean CD4 count changed from baseline (n=24) of 584.3 +- 685.9 mm3 to 614.4 +- 455.7 mm3 (n=15) at last follow up. One child developed minor skin rash in the initial two weeks of starting nevirapine. One child developed pancreatitis. We conclude that administration of nevirapine based ART for HIV-1 infected children is feasible in resource poor setting. There is improvement in growth parameters with use of this therapy.

Congenital stridor due to bilateral vocal cord palsy

Congenital stridor is one of the rare presentations of respiratory distress at birth. The commonest cause of congenital stridor is laryngomalacia, which accounts for 60% of the causes. The other common causes are congenital subglottic stenosis and vocal cord palsy (VCP). VCP is usually unilateral and most often linked with birth trauma, and is temporary. Bilateral palsy can be associated with other congenital anomalies. The current report describes a case of congenital bilateral VCP, not related to birth trauma and severe enough to require tracheostomy.

Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction

We have compared the results and complications after closed and open reduction with ternal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury.

Neonatal management of the growth-restricted infant

Close collaboration between obstetricians and neonatologists is essential for proper care of the growth-restricted fetus. A joint decision on the appropriate timing of delivery is made, based on the risk of fetal compromise compared with that of neonatal morbidity. A neonatal resuscitative team should be available at delivery. Gestational assessment, anthropological measurements and physical examination are necessary to confirm the diagnosis of intra-uterine growth retardation and establish the symmetric, asymmetric, combined or dysmorphic classification. Neonatal management requires special attention to a number of significant morbidities that growth-restricted infants are more prone to develop compared with normally grown infants, including asphyxia, meconium aspiration syndrome, respiratory distress syndrome, massive pulmonary haemorrhage, chronic lung disease, hypothermia, hypoglycaemia, hypocalcaemia, polycythaemia-hyperviscosity, intraventricular haemorrhage, sepsis, necrotizing enterocolitis, coagulation abnormalities, and congenital anatomical and genetic abnormalities. Intra-uterine growth retardation is associated with a higher stillbirth rate and infant mortality rate in preterm, term and post-term infants.

Continuous positive airway pressure - a gentler approach to ventilation

Continuous positive airway pressure (CPAP) has become a useful modality in management of respiratory distress, especially in preterm babies. Main indications for use of CPAP are respiratory distress syndrome (RDS) and apnea of prematurity. It decreases the need of invasive and costly mechanical ventilation. This review details the physiological effects of CPAP, its methods of delivery, and its need in a country like India. It also describes the guidelines for initiating and weaning CPAP. The review concludes that use of CPAP in respiratory distress syndrome is associated with lower rates of failed treatment, decreased incidence of chronic lung disease and lower overall mortality, specially in infants with birth weight above 1500 grams. Early use of CPAP is more beneficial, Surfactant and CPAP act in conjunction for babies with RDS. CPAP is a low-cost, simple and noninvasive option for a country like India, where most places lack facilities of mechanical ventilation. Systematic reviews, randomized and quasi-randomized trials by searching MEDLINE and the Cochrane Library formed the basis of this update.

Analgesic effect of expressed breast milk in procedural pain in term neonates: a randomized, placebo-controlled, double-blind trial

AIM

To assess the effectiveness of expressed breast milk (EBM) in reducing pain due to venepuncture, in term neonates, as measured by behavioural and physiological observations.

METHODS

This randomized, placebo-controlled, double-blind trial involved 81 full-term neonates, up to 4 wk of postnatal age, who needed venepuncture for blood investigations. Two minutes before the venepuncture, in the intervention arm, 40 babies received 5 ml of EBM, while 41 babies in control group received 5 ml of distilled water (DW) as placebo. Two observers who were blinded to the intervention recorded the physiological (heart rate and oxygen saturation) and behavioural parameters [duration of crying and modified Neonatal Facial Coding Scores (NFCS)] after the venepuncture.

RESULTS

There was no difference in the baseline characteristics of the neonates in the two groups. The duration of crying was significantly shorter in babies fed EBM [median 38.5 s, interquartile range (IQR) 9.5-57.5 s] than in those fed DW (median 90 s, IQR 28-210 s). The mean duration of crying in EBM group was shorter by 70.7 (95% confidence interval 36.6-104.9) s. The modified NFCS at 0, 1 and 3 min was significantly lower (p < 0.01) in the EBM than in the DW group. The change in heart rate and oxygen saturation was significantly lower in the EBM group and returned to baseline values sooner than in the DW group.

CONCLUSION

Feeding 5 ml of EBM before venepuncture is effective in reducing symptoms due to pain in term neonates.

Survival and morbidity in extremely low birth weight (ELBW) infants

We report the morbidity and mortality in extremely low birth weight neonates (ELBW) from a tertiary care hospital over seven years (1994-2000). Data regarding maternal and neonatal details was obtained from old records, computer database and medical files. Of the 12,807 live births during this period, 137 (1.07%) were ELBW infants. All of them were managed without surfactant. Overall, 67 infants (48.7%) survived to discharge. The most commonly encountered morbidities were hyperbilirubinemia(65%), respiratory distress(65%), sepsis(52%), intraventricular hemorrhage(29%), pneumonia (25%) and retinopathy of prematurity(24%). Need for resuscitation, pulmonary hemorrhage, seizures, acute renal failure, sclerema and air leak syndromes were significantly associated with mortality. Sepsis accounted for 41% of all deaths while immaturity was the second most important cause, accounting for 24% deaths. The average length of stay for survivors was 49 days (SD +/- 15.9 days)

Polycythemia in the newborn

Polycythemia is defined as a venous hematocrit above 65%. The relationship between viscosity and hematocrit is almost linear till 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypo-perfusion. The hematocrit in a newborn peaks at 2 hours of age and decreases gradually after that. The etiology of polycythemia is related either to intra-uterine hypoxia or secondary to fetal transfusion. Clinical features related to hyperviscosity may affect all organ systems and this entity should be screened for in high-risk infants. Polycythemia maybe symptomatic or asymptomatic and guidelines for management of both types are provided in the protocol.

Seizures in the newborn

Seizures in the newborn period constitute a medical emergency. Subtle seizures are mild paroxysmal alterations in motor or autonomic activity and are unique to the neonatal period. They are likely to be missed or confused with benign movements observed commonly in preterm children. Focal clonic seizures have a better prognosis as compared to myoclonic seizures for long-term neuro-developmental outcome. Seizures due to sub-arachnoid hemorrhage and late onset hypocalcemia carry a better prognosis as compared to seizures due to hypoglycemia, meningitis and cerebral malformations. Hypoglycemia and hypocalcemia are common causes and should be excluded in all neonates with seizures. Multiple etiologies can co-exist in neonatal seizures and a comprehensive approach for management of neonatal seizures has been described.

Palladium-catalyzed heteroannulation leading to heterocyclic structures with two heteroatoms: a highly regio- and stereoselective synthesis of (Z)-4-alkyl-2-alkyl(aryl)idene-3,4-dihydro-2H-1,4-benzoxazines and (Z)-3-alkyl(aryl)idene-4-tosyl-3,4-dihydro-2H-1,4-benzoxazines

A highly convenient method has been developed for the synthesis of (Z)-4-alkyl-2-alkyl(aryl)idene-3,4-dihydro-2H-1,4-benzoxazines 9 and (Z)-3-alkyl(aryl)idene-4-tosyl-3,4-dihydro-2H-1,4-benzoxazines 34-38 through palladium-copper-catalyzed reactions. Aryl halides 7 reacted with 2-[N-alkyl(benzyl)-N-prop-2'-ynyl]aminophenyl tosylate 6 in the presence of (PPh3)2PdCl2 (3 mol %), CuI(5 mol %) in triethylamine at room temperature to yield 2-[N-alkyl(benzyl)-N-(3-aryl-prop-2'-ynyl)]-aminophenyl tosylates 8 in extremely good yields (72-96%). The latter could then be cyclized with KOH in ethanol-water to Z-9 in a highly regio- and stereoselective manner. Similarly, palladium-copper-catalyzed reaction of 2-(prop-2'-ynyloxy)aniline (21) with aryl iodides 7 led to 22-26 which after tosylation and cyclization with cuprous iodide in CH3CN in the presence of K2CO3 and Bu4-NBr led to the (Z)-3-alkyl(aryl)idene-4-tosyl 3,4-dihydro-2H-1,4-benzoxazines 34-38 in good overall yields. The Z-stereochemistry of the products was established from 1H NMR spectra, 3JCH values (between vinylic proton and methylenic carbon of the heterocyclic ring), NOE experiments, and X-ray analysis. The method was also found to be suitable for the synthesis of bis(benzoxazinylated) derivatives 17, 39, and 2-alkyl-3,4-dihydro-2H-1,4-benzoxazines 18. Our method for the synthesis of 3,4-dihydro-2H-1,4-benzoxazines is highly efficacious, using easily available starting materials under very mild conditions. Also the synthesis of some novel 5-substituted uracil derivatives 40 and 41 containing the benzoxazinyl moiety and of potential biological interest is being reported.

Megalourethra: a report of four cases and review of the literature

Megalourethra is a rare congenital anomaly characterized by severe dilatation of the penile urethra. Four cases of congenital megalourethra were seen at Sir Padampat Mother and Child Health Institute, Jaipur, during the last 10 years. Three cases of scaphoid megalourethra had no other associated congenital anomalies and were treat-ed successfully without any complications, while one patient with a fusiform megalourethra had severe associated congenital anomalies and died. These cases are reported with a review of the literature.

Tuberculous chylous ascites: pathognomonic CT findings

The computed tomographic (CT) appearance of chylous ascites is usually that of water with corresponding attenuation coefficients. This case report depicts the fat-fluid level sign on CT (shown by supine and decubitus scans), which is pathognomonic of chylous ascites.

Antilipid peroxidative property of Nardostachys jatamanasi

Antiperoxidative property of N. jatamanasi was tested by using iron induced lipid peroxidation in 5% rat liver homogenate. The degree of peroxidation was quantitated by thiobarbituric acid reactive substance (TBARS) content. The extract provided protection against lipid peroxidation. The hexane fraction was more potent than the alcoholic extract. Results suggested antilipid peroxidative property of the plant.

Elective bedside tracheostomy in the intensive care unit

BACKGROUND

Tracheostomy is a frequently performed procedure, and historically has had a high reported complication rate. This has led some authors to suggest that a tracheostomy should be done only in the operating room (OR). Concerns regarding the hazards of transporting critically ill patients to the OR may inhibit the use of tracheostomy. Bedside tracheostomy in the Intensive Care Unit (ICU) has been shown to be safe, but this concept has not been widely accepted.

STUDY DESIGN

We retrospectively reviewed consecutive patients undergoing tracheostomy over a four-year period and compared the safety of elective beside tracheostomy with OR tracheostomy.

RESULTS

We studied 536 patients who underwent tracheostomy during the four years, in 470 of whom the procedures were elective. Of these, 66 percent were done at the bedside without an anesthesiologist present. For the 311 patients who underwent bedside tracheostomy, the complication rate was 8.7 percent compared to 9.4 percent of 159 patients undergoing OR tracheostomy (p values were not significant). No deaths were directly associated with tracheostomy procedures, although the overall hospital mortality rate for these patients was 59 percent.

CONCLUSIONS

A tracheostomy can safely be performed in an ICU without requiring transport of the patient to the operating suite, thereby eliminating the hazards of transport.

Bacopa monniera Linn. as an antioxidant: mechanism of action

Bacopa monniera, Linn. (Brahmi: Scrophulariaceae) an Ayurvedic medicine is clinically used for memory enhancing, epilepsy, insomnia and as mild sedative. For the first time the effect of alcohol and hexane fraction of Brahmi has been studied on FeSO4 and cumene hydroperoxide induced lipid peroxidation. Alcohol fraction showed greater protection with both inducers. Results were compared with known antioxidants tris, EDTA and a natural-antioxidant vitamin E. The effect of Brahmi was also examined on hepatic glutathione content. The mechanism of action could be through metal chelation at the initiation level and also as chain breaker. The results suggested that Brahmi is a potent antioxidant. The response of Brahmi was dose dependent. Tris, an hydroxyl trapper did not show any protection in comparison to Brahmi where as EDTA and vitamin E did protect against FeSO4. In experimental conditions 100 micrograms Brahmi extract (alcoholic) was equivalent to 247 micrograms of EDTA (0.66 microM) and 58 micrograms of vitamin E. Interestingly Brahmi only slightly protected the autooxidation and FeSO4 induced oxidation of reduced glutathione on lower doses 100 micrograms/ml and below, but on higher concentrations it enhanced the rate of oxidation.

A case control study of cancer cervix patients attending Command Hospital, Pune

A case control study was undertaken with the objective to determine the association of certain host factors like marital status, age at first marriage, duration of married life, parity, literary status and genital hygiene, in the subsequent development of cancer cervix. A total number of ninety-two cases and an equal number of control subjects, under matched case control design, were studied at Command Hospital, Pune over a period of nine months. Salient findings of this epidemiological study have been highlighted in this communication. Few of the risk factors viz early age at first marriage, longer duration of married life, increased and early parity, low educational status and poor genital hygiene were found to have played significant role in the subsequent development of carcinoma cervix.