Predictors of mortality in very low birth weight neonates in India

INTRODUCTION

Very low birth weight (VLBW) neonates constitute approximately 4-7 percent of all live births and their mortality is very high. The objective of the present study was to determine the predictors of mortality in VLBW neonates.

METHODS

A retrospective cohort of VLBW neonates admitted over three years was studied. Exclusion criteria were: (1) neonates weighing less than 500 g and with gestational age less than 26 weeks; (2) presence of lethal congenital malformations; and (3) death in the delivery room or within 12 hours of life. The outcome measure was in-hospital death. Medical records were reviewed and data was analysed. Univariate analysis and logistic regression analysis were done to determine the predictors of mortality.

RESULTS

A total of 260 cases were enrolled, of which a total of 96 (36.9 percent) babies died. The survival rate was found to increase with the increase in birth weight and gestational age. Univariate analysis showed maternal per vaginal bleeding, failure to administer steroid antenatally, Apgar score less than or equal to 5 at one minute, apnoea, gestational age, neonatal septicaemia and shock are the factors directly responsible for neonatal mortality. Logistic regression equation showed maternal bleed (1.326), apnoea (3.159), birth weight (0.037), gestational age (0.063), hypothermia (1.132) and shock (3.49) predicted 65 percent of mortality in VLBW babies.

CONCLUSION

Common antenatal and perinatal predictors of mortality in VLBW infants in India include maternal bleed, failure to administer antenatal steroids, low Apgar score, apnoea, extreme prematurity, neonatal septicaemia and shock.

High molecular mass multimer complexes and vascular expression contribute to high adiponectin in the fetus

CONTEXT

High plasma adiponectin concentrations in human fetuses and neonates are unique features of early developmental stages. Yet, the origins of the high adiponectin concentrations in the perinatal period remain elusive.

OBJECTIVE

This study was undertaken to identify the sources and functional properties of adiponectin in utero.

DESIGN AND METHODS

Tissue specimens were obtained at autopsy from 21- to 39-wk-old stillborn human fetuses. Adipose tissue and placenta were obtained at term elective cesarean section. Adiponectin complexes and expression were measured by immunodetection and real-time PCR.

RESULTS

Adiponectin mRNA transcripts were detected in fetal sc and omental adipose depots at lower concentrations than in maternal adipose tissue. Immunoreactive adiponectin was also observed in vascular endothelial cells of fetal organs, including skeletal muscle, kidney, and brain. The absence of adiponectin in all placental cell types and lack of correlation between maternal and umbilical adiponectin indicate that umbilical adiponectin reflects its exclusive production by fetal tissues. The most prominent forms of adiponectin in fetal plasma were high and low molecular mass (HMW and LMW) multimers of 340 and 160 kDa, respectively. The proportion of the HMW complexes was 5-fold (P < 0.001) higher in umbilical plasma than in adult. The high HMW and total adiponectin levels were associated with lower insulin concentration and lower homeostasis model of assessment of insulin resistance indices in umbilical plasma, reflecting higher insulin sensitivity of the fetus compared with adult.

CONCLUSIONS

The abundance of HMW adiponectin and its vascular expression are characteristics of human fetal adiponectin. Combined with high insulin sensitivity, fetal adiponectin may be a critical determinant of in utero growth.

Exact trait-model-free tests for linkage detection in pedigrees

A number of trait-model-free tests have been proposed for linkage detection between a genomic region and a trait. These tests involve testing the dependence in segregation between a trait and marker alleles by assigning a score to every possible identity-by-descent configuration of the pedigree members without modeling the trait, and then averaging the scores over all such configurations compatible with the observed marker genotypes and genealogical relationship of the pedigree members. In this paper we propose a permutation test as an alternative to the existing exact trait-model-free tests for linkage detection. The proposed test is computationally efficient and is applicable on complex multigeneration pedigree structures. In this paper, we have compared the performance of the permutation test with two other exact trait-model-free tests for linkage detection on simulated datasets. We have demonstrated that the proposed permutation test is fully robust against mispecification of marker allele frequencies and has very good power for linkage detection. The permutation test is implemented in the program lm_ibdtests within the framework of MORGAN 2.8 (http://www.stat.washington.edu/thompson/Genepi/MORGAN/Morgan.shtml).

Oncologic PET tracers beyond [(18)F]FDG and the novel quantitative approaches in PET imaging

In this review, we focus on the oncological applications of positron emission tomography (PET) tracers other than [(18)F]fluoro-2-deoxy-D-glucose (FDG) and the novel quantitative approaches in PET imaging. Oncological non-FDG PET tracers can be broadly categorized into 3 groups: those labeled with (18)F, (11)C and other non-FDG tracers. Fluorine-18 and (11)C are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. These tracers are also labeled with specific ligands for receptor imaging (i.e. estrogens, dihydrotestosterone or somatostatin). The other non-FDG radiotracers can be labeled with (68)Ga, (60)Cu, (64)Cu, etc. and are aimed to detect cell hypoxia, bone metabolism and receptor. Many of these have shown promising results in the management of various cancers where FDG has limited role. These radiotracers have more specific mechanism of uptake and is likely be investigated in the near future. In the era of fusion imaging, novel approaches for accurate quantitative analysis include partial volume correction for measured values in small lesions, dual-time point and delayed PET imaging, and global metabolic activity for assessment of various stages of disease. Major changes are likely to occur in the future that may overcome deficiencies that are associated with the current quantitative (standardized uptake value) techniques.

Antibiotic misuse in children by the primary care physicians--an Indian experience

OBJECTIVE

To determine the misuse of antibiotics in the Pediatric outpatients department' (OPD) of a busy teaching hospital and to ascertain the probable reasons behind it.

METHODS

Over a 6 months period, new cases primarily treated with antibiotics by Medical Officers (first contact physicians in Peadiatric Medicine and Surgery OPD) were recruited in the study after obtaining written consent from the parents. Various errors of antibiotic usage were noted. All Medical Officers were asked to fill up a preformed questionnaire and the parents/guardians were interviewed on their ideas about antibiotics. Data were analyzed by the statistical software SPSS 10.

RESULTS

Antibiotics were prescribed in 2427 (84.9%) new patients. Misuse of antibiotics was documented in 36.8% patients (no indication in 35.3%, improper selection in 17.9% and incorrect dosage in 7.7%). All medical officers were aware that they overuse antibiotics. The various reasons sited were demand of the parents, reluctance to counsel due to patient overload, free supply of medicines from OPD and sympathetic grounds as follow up visits were uncertain. Majority of the parents/attendants belonged to poor socioeconomic status and did not have any idea regarding antibiotics. All parents wanted quick relief without hospitalization and only 2.3% were willing to revisit the OPD for the same illness. Both medical officers and parents felt that base line investigations were unnecessary.

CONCLUSION

Antibiotic misuse is quite common in this part of the world. Irrational use was mostly seen in over-prescribing and improper selection of antibiotic. Poor socio-economic status and overcrowding of patients in OPD were the main responsible factors.

Obesity in pregnancy stimulates macrophage accumulation and inflammation in the placenta

Obesity and pregnancy are associated with a combination of insulin resistance and inflammatory changes which exacerbate in combination. Based on the similarity between the inflammatory transcriptomes of adipose tissue and placenta, we hypothesized that the placenta develops exaggerated inflammation in response to obesity. The aim of this study was to characterize placental inflammatory mediators and macrophage accumulation in relation to peripheral inflammation in obesity. Placental macrophages and maternal peripheral blood mononuclear cells (PBMC) from 20 obese and 15 lean women were functionally and phenotypically characterized using immunohistochemistry, flow cytometry and expression for macrophage markers and inflammatory cytokines. The number of resident CD68+ and CD14+ cells was increased 2-3 fold in the placenta of obese as compared to lean women. The macrophage population was characterized by a marked phenotypic heterogeneity with complex subsets of CD14+, CD68+ and CD11b+ (mac-1) cells and by an increased expression of the pro-inflammatory cytokines IL-1, TNF-alpha, IL-6. Placental inflammation was associated with an activation of PBMC gene expression with an increase in the monocyte differentiation and maturation markers CD14 and CD68 in maternal but not fetal PBMC. The inflammatory changes were associated with higher plasma concentrations of C-reactive protein and IL-6 in obese compared to lean women. In conclusion, the chronic inflammation state of pre-gravid obesity is extending to in utero life with accumulation of a heterogeneous macrophage population and pro-inflammatory mediators in the placenta. The resulting inflammatory milieu in which the fetus develops may have critical consequences for short and long term programming of obesity.

Prevention of nosocomial transmission of extensively drug-resistant tuberculosis in rural South African district hospitals: an epidemiological modelling study

BACKGROUND

Extensively drug-resistant (XDR) tuberculosis has spread among hospitalised patients in South Africa, but the epidemic-level effect of hospital-based infection control strategies remains unknown. We modelled the plausible effect of rapidly available infection control strategies on the overall course of the XDR tuberculosis epidemic in a rural area of South Africa.

METHODS

We investigated the effect of administrative, environmental, and personal infection control measures on the epidemic trajectory of XDR tuberculosis in the rural community of Tugela Ferry. Assessments were done with a mathematical model incorporating over 2 years of longitudinal inpatient and community-based data. The model simulated inpatient airborne tuberculosis transmission, community tuberculosis transmission, and the effect of HIV and antiretroviral therapy.

FINDINGS

If no new interventions are introduced, about 1300 cases of XDR tuberculosis are predicted to occur in the area of Tugela Ferry by the end of 2012, more than half of which are likely to be nosocomially transmitted. Mask use alone would avert fewer than 10% of cases in the overall epidemic, but could prevent a large proportion of cases of XDR tuberculosis in hospital staff. The combination of mask use with reduced hospitalisation time and a shift to outpatient therapy could prevent nearly a third of XDR tuberculosis cases. Supplementing this approach with improved ventilation, rapid drug resistance testing, HIV treatment, and tuberculosis isolation facilities could avert 48% of XDR tuberculosis cases (range 34-50%) by the end of 2012. However, involuntary detention could result in an unexpected rise in incidence due to restricted isolation capacity.

INTERPRETATION

A synergistic combination of available nosocomial infection control strategies could prevent nearly half of XDR tuberculosis cases, even in a resource-limited setting. XDR tuberculosis transmission will probably continue in the community, indicating the need to develop and implement parallel community-based programmes.

Poor follow-up rates at a self-pay northern Indian tertiary AIDS clinic

Background

In many developing countries, out-of-pocket payment remains a primary mechanism by which patients infected with HIV access treatment. In India, this has been changing as the National AIDS Control Organization (NACO) has been rolling out free antiretroviral therapy throughout the country since 2004. The vast majority of patients, however, remain without access to free medicines.

Methods

A retrospective chart review was performed on data obtained from a registry of ninety-three (93) patients attending a self-pay clinic at the All India Institute of Medical Sciences in Delhi, India. Multivariable Cox proportional hazard and logistic regression models were explored to assess the relationship between lost-to-follow-up status and the predictor variables: age, sex, household income, baseline CD4 count, and distance from clinic.

Results

Lost-to-follow-up rates were very high; 68% (63/93) were lost-to-follow-up till the time of chart review, including 59% (55/93) who were lost within one year. In both regression models, younger age, low baseline CD4 counts, and low income level were significantly associated with increased risk of lost-to-follow-up. Additionally, there was a significant interaction between income and CD4 counts. The patients with both low CD4 counts and low income level were more likely to be lost-to-follow-up than would be predicted by each covariable alone.

Conclusion

In this small cohort of AIDS patients attending a self-pay antiretroviral clinic at a large tertiary care center in Delhi, India, follow-up rates were quite poor. Poorer patients tended to present to clinic with more depressed CD4 counts and were less likely to be retained in care. These findings indicate that greater strides must be taken to improve the recruitment and retention of poor patients. The expansion of free antiretrovirals is one step among many necessary to achieve this objective.

Clinical profile and outcome of abdominal tuberculosis in Indian children

INTRODUCTION

Diagnosis of tuberculosis among children poses technical and operational challenges, more so in abdominal tuberculosis (ATB), where the protean clinical manifestations continue to challenge the physicians in its diagnosis and therapy.

METHODS

Medical records of 115 patients who were diagnosed with ATB over a period of six years were studied retrospectively. Details of history, physical examination and investigations, treatment and outcome of therapy were evaluated.

RESULTS

The mean age of the patients was 6.4 years. Commonest symptom at presentation was abdominal pain, followed by fever. Nine patients presented with acute abdomen. Mantoux test was positive in 33 percent and accelerated BCG reaction was found in 36.5 percent. Evidence of primary focus was found in 40 percent of chest radiographs. Commonest ultrasonography and computed tomography findings were mesenteric thickening, followed by intra-abdominal lymphadenopathy. Tuberculous infection could be confirmed in 38 patients. The classical plastic variety was the commonest type of ATB found. A complete cure with antituberculous drugs was documented in over 90 percent of the patients.

CONCLUSION

In high prevalence zones, ATB should be considered as a differential diagnosis in children presenting with non-specific constitutional symptoms and abdominal pain. When confirmatory tests are negative or not available, supportive investigations and clinical suspicion should be considered strongly for diagnosis of ATB to avoid delay in treatment. Response to therapy in such conditions indirectly confirms diagnosis. Timely use of laparoscopy and laparotomy may be required for confirmation of diagnosis.

Current knowledge on the distribution of arsenic in groundwater in five states of India

Testing of groundwater used for drinking for arsenic has been undertaken more widely by state governments in several states of India in recent years with the support of UNICEF. Available data for five states are collated in this paper and this provides the most up-to-date picture of areas known to be affected by arsenic in groundwater in the Indian portion of the Ganges-Brahmaputra river basin. In West Bengal, water from 132,262 government installed handpumps in 8 districts has been tested and overall 25.5% of samples were found to contain arsenic at concentrations greater than 50 microgL(-1) and 57.9% at concentrations greater than 10 microgL(-1). On the banks of the Brahmaputra in Assam, to date, samples from 5,729 government handpump sources in 22 districts have been tested for arsenic. Overall, samples from 6.3% of sources were found to contain arsenic at concentrations greater than 50 microgL(-1) and 26.1% at concentrations greater than 10 microgL(-1). In Bihar, on the River Ganges upstream of West Bengal, 66,623 sources from 11 districts have been tested and water samples from 10.8% of sources were found to contain arsenic at concentrations greater than 50 microgL(-1) and 28.9% at concentrations greater than 10 microgL(-1). Upstream of Bihar in Uttar Pradesh, home of the Taj Mahal, to date water samples from 20,126 government-installed handpump sources have been tested. As a result 2.4% of the samples tested were found to contain arsenic at concentrations greater than 50 microgL(-1) and 21.5% at concentrations greater than 10 microgL(-1). Finally in one district of Jharkhand, lying on the Ganges alluvial plain between Bihar and West Bengal, 9,007 sources have been tested and water samples from 3.7% of sources were found to contain arsenic at concentrations greater than 50 microgL(-1) and 7.5% at concentrations greater than 10 microgL(-1). State governments have adopted different sampling strategies and these are described in this paper. Testing is ongoing in several states and the complete picture is yet to emerge in some areas.

A hernia in the inguinal region is not always an inguinal hernia

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.