Effect of maternal low dose aspirin on neonatal platelet function

OBJECTIVE

To evaluate the effect of maternal low dose aspirin ingestion in platelet function of newborn.

DESIGN

Prospective randomized placebo controlled study.

METHODS

25 neonates born to mothers receiving low dose aspirin and 25 matched neonates with no maternal exposure to aspirin were studied. 2 ml of EDTA and 4.5 ml of citrate blood was collected from umbilical vein using double clamped umbilical stump for hemogram, coagulation profile and platelet functions.

RESULTS

The platelet counts (10(9)/l) of study and control groups were 186.4 +/- 22.76 (116-225) and 205.28 +/- 17.34 (176-225), respectively. There was no significant difference in coagulation parameters. Prothrombin time index (PTI) was 86.24 +/- 6.623 and 87 +/- 6.43, respectively in the study and control group while PTTK (sec) was 55.88 +/- 20.54 and 52.12 +/- 11.82 in study and control subjects, respectively. The platelet aggregation studies (platelet function) with various platelet agonists in study and control group did not show any significant difference. Clinically, none of the babies had bleeding.

CONCLUSIONS

Use of low dose aspirin in pregnant women was found to be safe and had no adverse effects on platelet functions of newborn.

Comparative ABR profile in high risk infants

Auditory brainstem responses (ABR) were studied in 52 children upto the age of 3 months, suffering from neonatal jaundice, prematurity, pyogenic meningitis and septicemia. Absolute latency of wave I and interpeak latency I-V were found to be significantly delayed in cases of jaundice and absolute latency of wave V and interpeak latency I-V were prolonged in cases with prematurity. In cases following pyogenic meningitis absolute latency of wave V and interpeak latency of I-III, I-V were significantly delayed compared to septicemia where absolute latency I, V and interpeak latency I-V were significantly delayed (P < 0.05). Maximum auditory insult was seen in cases with neonatal jaundice where 30.77% each had severe SN deafness and 30.77% had moderate degree of deafness compared to prematurity, meningitis and septicemia where 14.28, 7.69 and 25% were found to have severe SN deafness and 7.14, 38.46 and 25% had moderate deafness. Overall incidence of deafness of any kind in these factors was 44.23%.

Bone and joint infection in neonates

A retrospective study was done to review the clinical experience of septic arthritis and osteomyelitis in the newborns in our centre. Case records of all the neonates born from January 1989 to August 1994 and those admitted to outborn nursery from 1985 to 1993 were reviewed. Diagnosis of septic arthritis/osteomyelitis was made in the presence of relevant clinical signs and supported by positive culture from blood or joint fluid and abnormal X-ray or ultrasound findings. The incidence of septic arthritis and osteomyelitis among inborn babies was 1 in 1500. There were 25 neonates with mean gestational age 34.5 (range 27-40) weeks and mean birth weight 2269 (range 990-4750) gms. Limitation of movement (64%) and local swelling (60%) were commonest presentations. A total of 33 joints were involved in 25 babies. Eight babies (32%) had multiple joint involvement. Hip and knee were the most commonly involved joints (48% each). In 19 babies (76%) joint involvement occurred in association with a generalized septicemic illness while 6 babies (24%) had localised signs and symptoms. Joint aspirate was positive for gram stain or culture in 12 (48%) and 10 babies (40%) had positive blood culture. Klebsiella pneumoniae and Staphylococcus aureus were commonest isolates. Radiological changes were seen in 13 (52%) babies. All were treated with appropriate antibiotics and open surgical drainage was done in 5 (20%) cases. Bone and joint infections are important complications in sick septicemic neonates and need early diagnosis, appropriate management with antibiotics, surgical drainage in selected cases to prevent long term morbidity.

Epidemiology of systemic candidiasis in a tertiary care neonatal unit

143 neonates were diagnosed to have acquired systemic candidiasis out of a total 4530 admissions (3.2 per cent) to the neonatal intensive care unit (NICU) during a period of 6 1/2 years from January 1990 to June 1996. Mean age at onset was 10.4 days, mean birth weight 1454 g, and mean gestation was 31.7 weeks. Ninety-four per cent were premature, 95 per cent low birth weight (LBW), and all had undergone peripheral vein catheterization and had received broad spectrum antibiotics, except one, prior to the diagnosis. Fifty-eight per cent were ventilated and 15 per cent received parenteral nutrition. Persistent/recurrent pneumonia, apnoea, lethargy, high gastric aspirates, and abdominal distension were the common clinical manifestations. Candida tropicalis, C. albicans, and C. guillermondii were the most common isolates. Blood and urine were the predominant sites for isolation of Candida. Fluconazole was the most used antifungal agent, with 24 per cent resistance against it. Fifty per cent of babies died due to all causes. Of all the deaths, two-thirds were Candida related. Candida-attributable deaths occurred in 24 cases (17 per cent).

The steady states of microbial growth on mixtures of substitutable substrates in a chemostat

Microbes growing on mixtures of substrates in a chemostat exhibit different substrate utilization patterns, depending on the dilution rate and feed concentrations. For instance, when supplied with high feed concentrations of a binary mixture, both substrates are consumed at low dilution rates, but only one of the substrates is consumed at high dilution rates. The goal of this work is to explain the onset of such transitions, which play a very significant role in ecology and bioengineering. In previous work, we formulated a mathematical model of mixed-substrate growth in batch cultures. We use the extension of this model to continuous cultures as the framework for understanding substrate utilization patterns in continuous cultures. Our explanation rests upon the existence of two special types of dilution rates predicted by the model. The first is the so-called critical dilution rate at which the growth rate becomes zero, leading to cell washout. The existence of the critical dilution rate obtains from the simplest models of microbial growth, and is rooted in the fact that growth is inherently autocatalytic. The second type of special dilution rate, a unique feature of our model, stems from the recognition that synthesis of the enzymes catalysing the uptake of substrates is also autocatalytic. Hence, associated with each substrate is a transition dilution rate at which the synthesis rate of the transport enzyme becomes zero. We show that: (1) the substrate utilization patterns in continuous cultures are completely determined by the relative magnitudes of the critical and transition dilution rates; and (2) the critical and transition dilution rates are in turn determined by the feed concentrations. This allows us to construct an operating diagram, which yields the substrate utilization pattern for any given dilution rate and feed concentrations. The theory explains most of the mixed-substrate phenomena summarized in a recent review article by Egli (1995, Adv. Microbiol. Ecol. 14, 305-386).

Role of early postnatal dexamethasone in respiratory distress syndrome

OBJECTIVE

To study the effect of early postnatal dexamethasone therapy on severity of hyaline membrane disease.

DESIGN

Prospective, randomized, controlled, unblinded study.

SETTING

Neonatal Intensive Care Unit.

METHODS

19 babies who had hyaline membrane disease were included in this study. The inclusion criteria were clinical and radiographic diagnosis of RDS, requiring mechanical ventilation and FiO2 > 0.3. Ten babies received injection dexamethasone 0.5 mg/kg/dose 12 hourly for 3 days starting within 6 hours of birth. The control group did not receive any drug. Babies with active infection, bleeding tendency and congenital malformation were excluded. None of the babies received surfactant. The duration of ventilation and AaDO2 and FiO2 requirements from day one to five were calculated.

RESULTS

The initial AaDO2 were similar in both the groups but on day 3, 4, 5 AaDO2 were low in study group (201, 85, 70) compared to control group (236, 209, 162). The initial FiO2 were 0.66 and 0.63 in dexamethasone and control groups, respectively and remained high till day 2 and came down in study group on days 3, 4 and 5 (0.41, 0.27, 0.27) compared to control group (0.53, 0.34, 0.42). The mean duration of ventilation was shorter in dexamethasone group (87 hours) vs control group (120 hours).

CONCLUSION

Early use of postnatal dexamethasone reduces the disease severity and oxygen requirement in RDS and hence would be useful in the Indian context.

Anaerobes in neonatal septicaemia: a cause for concern

The purpose of this study was to determine the prevalence and vertical transmission of anaerobic infection in early onset neonatal septicaemia in babies born to mothers with adverse perinatal factors. One-hundred neonates born to mothers with one or more adverse perinatal factors were prospectively studied. Aerobic and anaerobic blood cultures were drawn in addition to rapid diagnostic tests. High vaginal swabs were also taken from all mothers prior to delivery. Anaerobic Clostridium species infection was found in 5 per cent babies and all of them were symptomatic. Fifteen babies had aerobic infection. There was one baby with concomitant aerobic and anaerobic infection. There was no significant difference in sex distribution, birth weight, or gestational age between babies with aerobic and anaerobic infection. Similarly, there were no symptoms unique to anaerobic infection. None of the rapid diagnostic tests had a good sensitivity for anaerobic infection. Fifty-two per cent of the mothers had anaerobic growth in their vaginal swabs, but none had transmitted to their babies. All five babies recovered within 24-72 h of commencing therapy. This study shows that anaerobes have a role in early onset neonatal septicaemia. They cause serious morbidity, but carry a good prognosis. For identification of such infection blood culture is mandatory.

Etiology of sporadic acute and fulminant non-A, non-B viral hepatitis in north India

BACKGROUND

Viral hepatitis is a major public health problem in India.

AIM

To investigate the association of various hepatitis viruses in patients with acute liver diseases in north India.

METHODS

One hundred and thirteen patients with acute viral hepatitis (AVH; n = 70) or fulminant hepatic failure (FHF; N = 43) were evaluated for the presence of hepatitis A, B, C and E virus infection. Hepatitis C virus (HCV) testing was done using second-generation anti-HCV ELISA test and reverse transcriptase polymerase chain reaction (PCR) for the detection of HCV RNA in the serum of patients with non-A, non-B (NANB) hepatitis. Detection of IgM anti-HEV antibody was done in patients found negative for the above viruses (n = 53).

RESULTS

Hepatitis A and B viruses accounted for 3.5% and 42.5% of the 113 cases, respectively. HCV infection accounted for 12% of the NANB cases with AVH and 15.5% with FHF. PCR was more useful than serological tests for the detection of HCV infection. HEV infection accounted for 49% of the NANB, non-C cases with AVH and 25% with FHF; pregnant women with HEV infection had a fulminant course. No etiological agent could be established in 28.3% of cases.

CONCLUSION

HEV is the most important cause of NANB hepatitis; hepatitis B virus is still a major concern, while HCV is not an important cause of acute viral liver disease in India.

Evolution of neonatal and pediatric critical care in India

During the last decade, the disciplines of neonatal and pediatric critical care have rapidly progressed in India. The growth of Neonatal Intensive Care has paced the growth of Pediatric Critical Care. The substantial growth of discipline and the positive improvements in neonatal outcomes are the results of the concerted efforts of the National Neonatal Forum and commitment of expatriate physicians residing in the United States. This article provides the background information regarding perinatal, neonatal, and infant mortalities in India. It also describes the maternal child health care delivery system in the Indian subcontinent.

Simplified assessment of asphyxia at birth

A simplified clinical method of assessment of the baby soon after birth was evaluated and compared with the cord blood pH and 1 min Apgar score. The assessment recorded cry, respiration, colour, activity, reflex response, and cord pulsation. Sixty-two neonates born at term by normal vaginal delivery with 1 min Apgar score of 0-6 (n = 31) and 7-10 (n = 31) were studied. Linear correlation coefficient (r) and Goodman's correlation coefficient (gamma) were used for statistical comparison. A combination of cry, colour and activity showed the best correlation with cord blood pH (r = 0.3842, P < 0.01: gamma = 0.7138) and 1 min Apgar score (r = 0.7768, P < 0.01, gamma = 0.9393) and was as useful as the combination of all the six clinical parameters. Illiterate traditional birth attendants can be safely taught to use cry, colour, and activity for assessing baby's condition at birth.

Photooxidant injury to glucose-6-phosphate dehydrogenase-deficient erythrocytes with bilirubin as the sensitizer--an in vitro study

To evaluate the hypothesis that glucose-6-phosphate dehydrogenase (G6PD)-deficient erythrocytes are more prone to photooxidant injury with bilirubin as the sensitizer, we compared the malonyl dialdehyde (MDA) levels and haematocrit values in 11 G6PD-deficient samples with a bilirubin: albumin molar ratio of 1:2 (10 mg% bilirubin, 2.5 g % albumin) photoexposed at 6 microW cm-2 nm-2 (420-460 nm), with 11 of control samples. Twelve hours after photoexposure the incremental changes in MDA levels (OD units) were higher in G6PD-deficient samples [mean (SE) = 0.230 (0.171) vs 0.075 (0.043), p < 0.01]. Antioxidant drugs may have a protective role while G6PD-deficient neonates undergo phototherapy.

Small for gestational age babies: Indian scene

Intrauterine growth retardation (IUGR) is an important determinant of neonatal mortality, morbidity and poor neurologic outcome. The study was aimed to evaluate the magnitude of perinatal risk factors in causation and the neonatal outcome of small for gestational age (SGA) babies. One hundred and three SGA babies born over a period of one year were retrospectively analysed during their hospital stay. 3.53 per cent of the babies were SGA with mean birth weight of 1657 +/- SD 354 gm (range 600-2200 gm). 68.9 per cent were term babies and 51.5 per cent were females. Toxemia of pregnancy (30.09%), hypertensive diseases of pregnancy (HDP) excluding toxemia (5.8%), diabetes mellitus (1.94%), medical disorders including renal and cardiac (3.88%), anemia (Hb < 8 gm%) and IU infection (0.97%) were the main conditions responsible for SGA. In 56.3% pregnancies, no cause could be ascertained. The common perinatal problems were infections in 27 (26.2%), birth asphyxia in 22 (21.36%), polycythemia in 25 (24.3%), jaundice in 22 (21.36%) and hypoglycemia in 7 (6.8%). Congenital malformations in 2 (1.94%) and Hyaline membrane disease in 1 (0.97%) were uncommon problems. 5.8 per cent babies died due to various perinatal problems. Based on these findings it was concluded that idiopathic (? Constitutional) intrauterine growth retardation was the commonest cause of SGA in Indian babies. 58.3 per cent babies had neonatal problems and they had a better survival compared to their western counterparts.

Fluconazole

Incidence of systemic candidiasis is increasing with improvement in the survival of high risk neonates who undergo multiple interventions. Therapies available to treat systemic fungal infection are few and have several drawbacks. Fluconazole, a new triazole derivative may be a useful anti-fungal agent in view of its excellent oral absorption, easy administration, low plasma protein affinity, long half-life, high concentrations in urine and CSF, minimal adverse reactions, wide spectrum of anti-fungal activity and high specificity for fungal cytochrome P450 system. Its utility in neonates and children with candidiasis has already been documented by few case reports and studies.

Fluconazole in the management of neonatal systemic candidiasis

OBJECTIVE

To evaluate the role of Fluconazole in the management of neonatal systemic candidiasis.

DESIGN

Descriptive, retrospective analysis.

SUBJECTS

23 neonates diagnosed as systemic candidiasis based on clinical suspicion with blood and/or urine culture positive for candida were treated with Fluconazole (5 mg/kg/day) for > 7 days.

RESULTS

Babies had mean birth weight 1590 + 533 g, mean gestation 32.3 + 3.1 wks and fungal sepsis was diagnosed at a mean age of 14.3 + 7.9 days. Candida albicans (43.5%), C. tropicalis (21.7%), C. guillermondii (13%), C. parapsillosis (13%) and C. krusei (8.7%) were the species isolated. Fluconazole was effective in 82.3% cases with no side effects. Four resistant cases were C. parapsillosis (n = 2), C. albicans (n = 1) and C. guillermondii (n = 1) and there were three deaths, all in resistant cases though one death was unrelated to candidemia.

CONCLUSION

Fluconazole is a safe and effective drug for neonatal systemic candidiasis.

A prospective study of delta infection in fulminant hepatic failure

Thirty one patients of HBV related Fulminant Hepatic Failure (FHF) were studied for the presence of delta infection and subsequently the clinical features, course and outcome of the delta infected cases was compared with those of delta uninfected cases. Out of 31 patients studied, 11 patients (35.8%) were reactive for anti-delta antibodies. There was no significant difference in age in delta reactive and non-reactive group. Hepatic encephalopathy was seen in all of the patients. The mean SGOT and SGPT were 378 +/- 88.74 U and 454 +/- 70.44 U respectively in anti-delta reactive group as compared to 239 +/- 74.94 U and 274.1 +/- 100.34 U respectively in anti-delta non reactive group (p < 0.05). During follow up, 10/11 patients (91%) died in anti-delta reactive group as compared to 13/20 patients (65%) in anti-delta non reactive group. So this study suggests that delta virus infection is quite common in India and it lead to excerbation of illness and carries a relatively poor prognosis for FHF.