Evidence of a Hardening in the Cosmic Ray Proton Spectrum at around 166 TeV Observed by the GRAPES-3 Experiment

We present the measurement of the cosmic ray proton spectrum from 50 TeV to 1.3 PeV using 7.81×10^{6} extensive air shower events recorded by the ground-based GRAPES-3 experiment between 1 January 2014 and 26 October 2015 with a live time of 460 day. Our measurements provide an overlap with direct observations by satellite and balloon-based experiments. The electromagnetic and muon components in the shower were measured by a dense array of plastic scintillator detectors and a tracking muon telescope, respectively. The relative composition of the proton primary from the air shower data containing all primary particles was extracted using the multiplicity distribution of muons which is a sensitive observable for mass composition. The observed proton spectrum suggests a spectral hardening at ∼166  TeV and disfavors a single power law description of the spectrum up to the Knee energy (∼3  PeV).

Prophylactic Acid-suppression Medication to Prevent Anastomotic Strictures After Oesophageal Atresia Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Anastomotic stricture is a common postoperative complication of oesophageal atresia ± tracheoesophageal fistula (OA/TOF) repair. Acid gastro-oesophageal reflux disease (GORD) is considered to be a factor in stricture formation and acid suppression medication is recommended post-operatively in consensus guidance. We aimed to investigate whether patients who were treated prophylactically with acid suppression medication had a reduced incidence of strictures compared to those who did not receive it.

METHODS

A systematic review of studies was performed, searching multiple databases without language or date restrictions. Multiple reviewers independently assessed study eligibility and literature quality. The primary outcome was anastomotic stricture formation, with secondary outcomes of GORD, anastomotic leak, and oesophagitis. Meta-analysis was performed using a random effects model, and the results were expressed as an odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

No randomised studies on the topic were identified. Twelve observational studies were included in the analysis with ten reporting the primary outcome. The quality assessment showed a high risk of bias in several papers, predominantly due to non-objective methods of assessment of oesophageal stricture and the non-prospective, non-randomised nature of the studies. Overall, 1395 patients were evaluated, of which 753 received acid suppression medication. Meta-analysis revealed a trend towards increased odds of anastomotic strictures in infants receiving prophylactic medication, but this was not statistically significant (OR 1.33; 95% CI 0.92, 1.92). No significant differences were found in secondary outcomes.

CONCLUSIONS

This meta-analysis found no evidence of a statistically significant link between the prophylactic prescribing of acid suppression medication and the risk of developing anastomotic stricture after OA repair. The literature in this area is limited to observational studies and a randomised controlled trial is recommended to explore this question.

LEVEL OF EVIDENCE

Level III.

Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants: Follow-Up of the OPTIMIST-A Randomized Clinical Trial

Importance

The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified.

Objective

To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age.

Design, Setting, and Participants

Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022.

Interventions

Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment.

Main Outcomes and Measures

The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years.

Results

Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]).

Conclusions and Relevance

In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life.

Trial Registration

anzctr.org.au Identifier: ACTRN12611000916943.

Early childhood parent-reported speech problems in small and large for gestational age term-born and preterm-born infants: a cohort study

OBJECTIVE

(1) To assess if preterm and term small for gestational age (SGA) or large for gestational age (LGA) infants have more parent-reported speech problems in early childhood compared with infants with birth weights appropriate for gestational age (AGA). (2) To assess if preterm and term SGA and LGA infants have more parent-reported learning, behavioural, hearing, movement and hand problems in early childhood compared with AGA infants.

DESIGN

Cohort study.

SETTING

Wales, UK.

PARTICIPANTS

7004 children with neurodevelopmental outcomes from the Respiratory and Neurological Outcomes of Children Born Preterm Study which enrolled 7129 children, born from 23 weeks of gestation onwards, to mothers aged 18-50 years of age were included in the analysis.

OUTCOME MEASURES

Parent-reported single-answer questionnaires were completed in 2013 to assess early childhood neurodevelopmental outcomes. The primary outcome was parent-reported speech problems in early childhood adjusted for clinical and demographic confounders in SGA and LGA infants compared with AGA infants. Secondary outcomes measured were parent-reported early childhood learning, behavioural, hearing, movement and hand problems.

RESULTS

Median age at the time of study was 5 years, range 2-10 years. Although the adjusted OR was 1.19 (0.92 to 1.55) for SGA infants and OR 1.11 (0.88 to 1.41) for LGA infants, this failed to reach statistical significance that these subgroups were more likely to have parent-reported speech problems in early childhood compared with AGA infants. This study also found parent-reported evidence suggestive of potential learning difficulties in early childhood (OR 1.51 (1.13 to 2.02)) and behavioural problems (OR 1.35 (1.01 to 1.79)) in SGA infants.

CONCLUSION

This study of 7004 infants in Wales suggests that infants born SGA or LGA likely do not have higher risks of parent-reported speech problems in early childhood compared with infants born AGA. To further ascertain this finding, studies with wider population coverage and longer-term follow-up would be needed.

Immune and metabolic markers for identifying and investigating severe Coronavirus disease and Sepsis in children and young people (pSeP/COVID ChYP study): protocol for a prospective cohort study

INTRODUCTION

Early recognition and appropriate management of paediatric sepsis are known to improve outcomes. A previous system's biology investigation of the systemic immune response in neonates to sepsis identified immune and metabolic markers that showed high accuracy for detecting bacterial infection. Further gene expression markers have also been reported previously in the paediatric age group for discriminating sepsis from control cases. More recently, specific gene signatures were identified to discriminate between COVID-19 and its associated inflammatory sequelae. Through the current prospective cohort study, we aim to evaluate immune and metabolic blood markers which discriminate between sepses (including COVID-19) from other acute illnesses in critically unwell children and young persons, up to 18 years of age.

METHODS AND ANALYSIS

We describe a prospective cohort study for comparing the immune and metabolic whole-blood markers in patients with sepsis, COVID-19 and other illnesses. Clinical phenotyping and blood culture test results will provide a reference standard to evaluate the performance of blood markers from the research sample analysis. Serial sampling of whole blood (50 μL each) will be collected from children admitted to intensive care and with an acute illness to follow time dependent changes in biomarkers. An integrated lipidomics and RNASeq transcriptomics analyses will be conducted to evaluate immune-metabolic networks that discriminate sepsis and COVID-19 from other acute illnesses. This study received approval for deferred consent.

ETHICS AND DISSEMINATION

The study has received research ethics committee approval from the Yorkshire and Humber Leeds West Research Ethics Committee 2 (reference 20/YH/0214; IRAS reference 250612). Submission of study results for publication will involve making available all anonymised primary and processed data on public repository sites.

TRIAL REGISTRATION NUMBER

NCT04904523.

Design and operation of a hybrid LED/LD-pumped phosphor-converted white-light lamp

Illumination sources based on phosphors, pumped by laser diodes (LDs), have seen rapid developments over the past decade. Here, we present a new, to the best of our knowledge, design that features both spectral richness and the capability for high brightness. Complete design details and operational characterization have been described. This basic design can be extended in various ways to customize such lamps for different operational requirements. A hybrid arrangement of both LEDs and an LD is used to excite a mixture of two phosphors. The LEDs, in addition, provide a blue fill-in to enrich output radiation and to tune the chromaticity point inside the white region. The LD power, on the other hand, can be scaled up to generate very high brightness levels that are not achievable with pumping from LEDs alone. This capability is gained using a special transparent ceramic disk that carries the remote phosphor film. We also show that the radiation from our lamp is free from speckle-producing coherence.

Measuring the impact of deprivation on learning difficulties and behaviour among infants born preterm: A cohort study

BACKGROUND

Preterm birth and social deprivation are known risk factors for learning difficulties. However there has been little work looking into the interaction between these two risks. We aimed to identify if children born preterm to families with higher levels of social deprivation are disproportionately more likely to have learning difficulties than those with lower levels of social deprivation.

METHODS

Data from the RANOPS (Respiratory And Neurological Outcomes in children born Preterm Study) was used to assess prevalence of learning difficulties. The effects of preterm birth and deprivation were reviewed. Multi-level logistic regression models were used to examine if gestational age and deprivation impacts interacted after adjustment for possible confounders. Primary outcome measure was parent-reported learning difficulties. Secondary outcome measures were parent-reported behavioural problems and a statement of special educational need.

RESULTS

We investigated the developmental outcomes of 6,691 infants with a median age of 5 years at time of survey (IQR 5). Deprivation decile (OR 1.08 (1.03,1.12)) and preterm birth (OR 2.67 (2.02,3.53)) were both associated with increased risk of learning difficulties. There was little evidence for any interaction between preterm birth and deprivation (p = 0.298) and the risk of learning difficulties.

CONCLUSIONS

Deprivation and preterm birth have significant associations with learning difficulties. While deprivation does not appear to have potentiated the impact of preterm birth, preterm infants in the most deprived areas have the highest risk of learning difficulties with almost 1 in 3 extremely premature infants with a learning difficulty in the most deprived areas.

mSep: investigating physiological and immune-metabolic biomarkers in septic and healthy pregnant women to predict feto-maternal immune health - a prospective observational cohort study protocol

INTRODUCTION

Maternal sepsis remains a leading cause of death in pregnancy. Physiological adaptations to pregnancy obscure early signs of sepsis and can result in delays in recognition and treatment. Identifying biomarkers that can reliably diagnose sepsis will reduce morbidity and mortality and antibiotic overuse. We have previously identified an immune-metabolic biomarker network comprising three pathways with a >99% accuracy for detecting bacterial neonatal sepsis. In this prospective study, we will describe physiological parameters and novel biomarkers in two cohorts-healthy pregnant women and pregnant women with suspected sepsis-with the aim of mapping pathophysiological drivers and evaluating predictive biomarkers for diagnosing maternal sepsis.

METHODS AND ANALYSIS

Women aged over 18 with an ultrasound-confirmed pregnancy will be recruited to a pilot and two main study cohorts. The pilot will involve blood sample collection from 30 pregnant women undergoing an elective caesarean section. Cohort A will follow 100 healthy pregnant women throughout their pregnancy journey, with collection of blood samples from participants at routine time points in their pregnancy: week 12 'booking', week 28 and during labour. Cohort B will follow 100 pregnant women who present with suspected sepsis in pregnancy or labour and will have at least two blood samples taken during their care pathway. Study blood samples will be collected during routine clinical blood sampling. Detailed medical history and physiological parameters at the time of blood sampling will be recorded, along with the results of routine biochemical tests, including C reactive protein, lactate and white blood cell count. In addition, study blood samples will be processed and analysed for transcriptomic, lipidomic and metabolomic analyses and both qualitative and functional immunophenotyping.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Wales Research Ethics Committee 2 (SPON1752-19, 30 October 2019).

TRIAL REGISTRATION NUMBER

NCT05023954.

Non-invasive respiratory support in preterm infants

Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials.

O-031 Activation of NLRP3 inflammasome enhances neutrophil extracellular traps in women with stage III/IV endometriosis: convergence of multiple signaling portray association between genetics and lesion type

Study question

Do NOD-like receptor pyrin-containing 3 (NLRP3) signaling affect neutrophil extracellular traps (NET)-osis in women with stage III/IV endometriosis?

Summary answer

Inflammasome activation whether due to pathogen (disease itself) or damage-associated molecular pattern (through NET) might be one mechanism involved in establishing perturbed endometrium in endometriosis.

What is known already

Endometriosis is characterized by number of processes like vascularization, hypernociception, and fibrosis, cardinal cause being inflammation. Recently, expression of inflammasome components, including NLRP3 and apoptosis signal-regulating kinase has been demonstrated in human endometrium cueing involvement in uterine innate immunity. Moreover, a novel extracellular killing mechanism, NET, is documented to reflect an inflammatory status in deep infiltrating endometriosis. Since, endometriosis demonstrates similarities with chronic inflammatory and autoimmune disorders; we postulated inflammatory responses in endometriosis may become modulated through a feed-forward loop of NET-induced specific cytokine production thus providing insights against potentiality of endometriotic cells to limit progression of the disease.

Study design, size, duration

Twenty-two consented women (24-39 years) with endometriosis (Group A) (Stages III–IV) (based on ASRM-2018 guidelines) and age-matched counterpart/s of male sub-fertility (Group B; control), free of uterine abnormalities (n = 18) were recruited between January to December 2021 from Institute of Reproductive Medicine, Kolkata. Eutopic endometrium, were collected from women undergoing diagnostic laparoscopy (Group A) or by curettage from women undergoing endometrial ablation (Group B). Serum was collected during window-of-implantation (LH + 7) for both the group/s.

Participants/materials, setting, methods

Pro-(IFN-g, TNF-a, IL-6, TGF-b) and anti-inflammatory (IL-10, IL-13, IL-4, IL-5) cytokines was evaluated by western blot. Expression level of inflammasome-related proteins (NLRP3, ASC, CASPASE1, PYCARD, IL-1-b) and mRNA expression was estimated by western-blot and quantitative-real-time PCR (qRT-PCR) respectively from tissue biopsies in Group A and B. SYTOX® green assay by flow-cytometry and neutrophil-elastase activity by immunofluorescence was done to quantify and characterize NET production in blood monocytes. P < 0.05 was considered statistically significant.

Main results and the role of chance

The mean (±SD) age of study population was 31.6±5.2 years. Hyperestrogenic milieu possibly stimulated (p < 0.001) pro-inflammatory molecules (IFN-g, TNF-a, IL-6, TGF-b) in endometriosis as observed by western-blot and qRT-PCR. A significant up-regulation (p < 0.001) was observed in relative mRNA expression of NLRP3 and PYCARD gene in Group A. However, caspase 1 expression documented non-significant variation in biopsies from endometriosis patients. Western blot corroborated the finding/s. The outcome of NLRP3 activation was supported by increased (p < 0.002) mRNA expression of IL-1b. NETs were detected significantly higher (p < 0.01) in 54.54% (12/22) patients in group A compared to control (16.66%; (3/18)). Moreover, quantification of NETs showed a significantly higher amount in endometriosis compared to group B (0.097 vs. 0.02, p < 0.03).

Spermann-rank correlation by SPSS version22 revealed positive correlation between IL-1b with NLRP3 (r = 0.56, p< 0.001), PYCARD (r = 0.11, p< 0.01); and caspase1 (r = 0.16, p< 0.01) and IL-1b (r = 0.47, p< 0.01) with NET-positive cell/s in endometriosis. Moreover, posterior cul-de-sac lesions correlated positively with NET-positive cell/s (r = 0.29; p < 0.01) cueing to possible prognostic marker/s. In summary, a coordinated-fashioned action of components of NLRP3 inflammasome machinery may regulate production of NET/s forming a complex network allowing communication between cell-types in order to maintain viability and development of endometrial lesion/s.

Limitations, reasons for caution

Our findings need to be replicated in larger study cohort/s, especially stratified by severity of endometriosis sub-groups and in women of different ethnicities. Another limitation is the missing information about NETs in normal functioning human endometrium throughout the menstrual cycle.

Wider implications of the findings

The proposed study aims to understand potential role of NLRP3 inflammasome complex as a “double-edged sword” in the development and pathophysiology of endometriosis. Therapeutic alternatives that aim to re-balance the pro- to anti-inflammatory milieu in the endometrium should consider the inflammasome as part of the equation.

Trial registration number

Not applicable

P-390 Serum homocysteine and uterine artery Doppler ultrasound in combination has better predictive accuracy in women with preeclampsia: useful tool for early screening in everyday practice

Study question

Is serum homocysteine combined with uterine-artery Doppler were effective in predicting preeclampsia (≥140mmHg/≥90mmHg blood pressure) in singleton pregnancy during 11–15 weeks of gestation?

Summary answer

Combination of serum homocysteine levels with uterine-artery Doppler is superior to individual presence of biochemical/ultrasound marker/s making the duo effective for early screening in preeclampsia.

What is known already

American College of Obstetricians and Gynecologists and National Institute for Care and Health Excellence recommend identifying patients who are at high risk of developing preeclampsia based on medical history. Recently, biochemical and ultrasound markers were investigated for prediction of preeclampsia, but none of them were predictably reliable, valid, and suitable for routine clinical use. Increased levels of homocysteine in 1st-trimester, seems to signal onset of preeclampsia later in pregnancy portraying severity of the disease as well. We aimed to identify predictive value of serum homocysteine combined with uterine-artery Doppler in singleton pregnancy during 11–15 weeks of gestation for preeclampsia.

Study design, size, duration

One hundred forty-two consented singleton pregnant women (28-45 years) at gestational age of 11–15 weeks, recruited between January to December 2021 from Institute of Reproductive Medicine, Kolkata were enrolled in the study. Women who used aspirin as a prophylaxis for preeclampsia or were diagnosed to have fetal, structural or chromosomal abnormalities were excluded from the study (n = 7). Maternal age, weight and height, mean arterial pressure, parity, and obstetric history were documented.

Participants/materials, setting, methods

Uterine-artery Doppler ultrasound and serum homocysteine levels were performed transabdominally and using ELISA respectively. Pregnancy outcomes were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at optimal cut-off values were determined to predict preeclampsia. Optimal cut-off values for homocysteine levels were calculated using receiver operator characteristic curve (ROC). Chi-square test, Fisher’s exact test, unpaired t test, and Mann–Whitney U test were used when appropriate. P-value <0.05 was considered statistically significant.

Main results and the role of chance

16 cases had preeclampsia (11.26%) of whom 9 had early-onset preeclampsia (6.33%). Baseline characteristics including maternal-age (>35 or<), parity, body-mass- index, and gestational-age at measurement were not significantly different between two groups excepting higher (p < 0.001) mean arterial blood pressure (mmHg) at first trimester (97.2±6.4 vs. 81.1±7.2) in preeclampsia. Preeclamptic women had significantly higher (p < 0.001) serum homocysteine levels (μmol/l) (26.1±3.5 vs 10.2± 5.6) than normotensive pregnant women (n = 119). No difference in mean pulsatility (PI) of uterine-artery was observed (1.78±0.64 vs. 1.72±0.48) excluding significantly high (p > 0.02) in women with early-onset preeclampsia than control (2.11±0.81 vs. 1.39±0.92). However, lower (p < 0.01) gestational age (weeks) (35.4±2.1 vs. 37.6±1.4), and neonatal birth weight (gms) (2937.3±578.2 vs. 3227.6±421.5) with higher (p < 0.001) preterm delivery (25% vs 5.04%), low birth weight (25% vs 5.04%) and neonatal respiratory distress syndrome (12.5% vs. 0.84%) was documented in preeclampsia than control/s. The optimal cut-off value of serum homocysteine with PI levels, from ROC (AUC=0.735, p < 0.001) was superior to individual ROC (AUC=0.451; AUC=0.268). The sensitivity, specificity, PPV, and NPV were 67.7%, 70.5%, 1.7%, and 98.5%, respectively using a combination of abnormal serum homocysteine levels with abnormal uterine artery Doppler PI (above 95th percentile) and used as a predictive value for preeclampsia.

Limitations, reasons for caution

The limitation of this study was that there were small cases of early-onset preeclampsia. Additional studies with a larger sample size of early-onset preeclampsia and other models using serum homocysteine, combined with uterine artery Doppler, and maternal characteristic risk factors should be conducted.

Wider implications of the findings

Early screening of preeclampsia by using combination of serum homocysteine and uterine artery Doppler during first trimester (11–15 weeks) at the same visit may be more effective and allows the timing for using early low-dose aspirin prophylaxis in order to prevent preeclampsia.

Trial registration number

Not applicable

Global health systems' data science approach for precision diagnosis of sepsis in early life

Neonates and children in low-income and middle-income countries (LMICs) contribute to the highest number of sepsis-associated deaths globally. Interventions to prevent sepsis mortality are hampered by a lack of comprehensive epidemiological data and pathophysiological understanding of biological pathways. In this review, we discuss the challenges faced by LMICs in diagnosing sepsis in these age groups. We highlight a role for multi-omics and health care data to improve diagnostic accuracy of clinical algorithms, arguing that health-care systems urgently need precision medicine to avoid the pitfalls of missed diagnoses, misdiagnoses, and overdiagnoses, and associated antimicrobial resistance. We discuss ethical, regulatory, and systemic barriers related to the collection and use of big data in LMICs. Technologies such as cloud computing, artificial intelligence, and medical tricorders might help, but they require collaboration with local communities. Co-partnering (joint equal development of technology between producer and end-users) could facilitate integration of these technologies as part of future care-delivery systems, offering a chance to transform the global management and prevention of sepsis for neonates and children.

ADRENAL HISTOPLASMOSIS: AN EASTERN INDIAN PERSPECTIVE

CONTEXT

The clinical presentation of histoplasmosis is varied. Due to its propensity for adrenal involvement, histoplasmosis is an important differential diagnosis in any patient presenting with adrenal mass, bilateral in particular.

OBJECTIVE

Data on clinical presentation, pattern of adrenal involvement, radiological appearance and long-term follow-up of adrenal histoplasmosis are relatively sparse; hence we looked at it.

DESIGN

This record based single-centre retrospective study was conducted in one of the tertiary care hospitals, situated in eastern India catering the Gangetic delta.

SUBJECTS AND METHODS

Data on demographic characters, presenting manifestations, biochemical & hormonal parameters and radiological appearance of confirmed adrenal histoplasmosis cases (n=9), admitted between 2015-2019 have been retrieved. The treatment outcome and condition of patients after 1-4 years of follow-up has also been discussed.

RESULTS

Four out of the nine (44.4%) patients had predisposing immunocompromised conditions in the form of diabetes and/or chronic alcoholism while rest were immunocompetent. Seven out of nine patients (77.8 %) had signs and symptoms suggestive of adrenal insufficiency, while two (22.2%) presented with only pyrexia of unknown origin. All of them had bilateral adrenal mass, though the radiologically appearances were different. All patients received anti-fungal agents with/without hydrocortisone and/or fludrocortisone. One patient died (11.1%), while majority responded favourably to treatment. Adrenocortical function did not recover completely.

CONCLUSIONS

The possibility of adrenal histoplasmosis should always be considered in patients presenting with bilateral adrenal mass, irrespective of adrenal morphology. Treatment is effective, but many of them require supplemental hydrocortisone for quite a long period, if not lifelong. Mineralocorticoid deficiency, however, is not permanent.

nSeP: immune and metabolic biomarkers for early detection of neonatal sepsis-protocol for a prospective multicohort study

INTRODUCTION

Diagnosing neonatal sepsis is heavily dependent on clinical phenotyping as culture-positive body fluid has poor sensitivity, and existing blood biomarkers have poor specificity.A combination of machine learning, statistical and deep pathway biology analyses led to the identification of a tripartite panel of biologically connected immune and metabolic markers that showed greater than 99% accuracy for detecting bacterial infection with 100% sensitivity. The cohort study described here is designed as a large-scale clinical validation of this previous work.

METHODS AND ANALYSIS

This multicentre observational study will prospectively recruit a total of 1445 newborn infants (all gestations)-1084 with suspected early-or late-onset sepsis, and 361 controls-over 4 years. A small volume of whole blood will be collected from infants with suspected sepsis at the time of presentation. This sample will be used for integrated transcriptomic, lipidomic and targeted proteomics profiling. In addition, a subset of samples will be subjected to cellular phenotype and proteomic analyses. A second sample from the same patient will be collected at 24 hours, with an opportunistic sampling for stool culture. For control infants, only one set of blood and stool sample will be collected to coincide with clinical blood sampling. Along with detailed clinical information, blood and stool samples will be analysed and the information will be used to identify and validate the efficacy of immune-metabolic networks in the diagnosis of bacterial neonatal sepsis and to identify new host biomarkers for viral sepsis.

ETHICS AND DISSEMINATION

The study has received research ethics committee approval from the Wales Research Ethics Committee 2 (reference 19/WA/0008) and operational approval from Health and Care Research Wales. Submission of study results for publication will involve making available all anonymised primary and processed data on public repository sites.

TRIAL REGISTRATION NUMBER

NCT03777670.

Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial

IMPORTANCE

The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain.

OBJECTIVE

To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020.

INTERVENTIONS

Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately.

RESULTS

Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group.

CONCLUSIONS AND RELEVANCE

Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000916943.

Volatile organic compounds as disease predictors in newborn infants: a systematic review

Volatile organic compounds (VOC) detected in human breath, urine, stool, sweat, saliva, and blood result from metabolic processes in the body during health or disease. Using sophisticated measurement systems, small amounts of these compounds can be detected in the above bodily fluids. Multiple studies in adults and children have shown the potential of these compounds to differentiate between healthy individuals and patients by detecting profiles of compounds in non-invasively collected samples. However, the detection of biomarkers in VOCs from neonates is particularly attractive due to the non-invasive nature of its approach, and its ability to track disease progress by longitudinal sampling. In this work we have reviewed the literature on the use of VOCs in neonates and identified areas for future work.

Temporal trends of care practices, morbidity, and mortality of extremely preterm infants over 10-years in South Wales, UK

Contemporary outcome data of preterm infants are essential to commission, evaluate and improve healthcare resources and outcomes while also assisting professionals and families in counselling and decision making. We analysed trends in clinical practice, morbidity, and mortality of extremely preterm infants over 10 years in South Wales, UK. This population-based study included live born infants < 28 weeks of gestation in tertiary neonatal units between 01/01/2007 and 31/12/2016. Patient characteristics, clinical practices, mortality, and morbidity were studied until death or discharge home. Temporal trends were examined by adjusted multivariable logistic regression models and expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). A sensitivity analysis was conducted after excluding infants born at < 24 weeks of gestation. In this population, overall mortality for infants after live birth was 28.2% (267/948). The odds of mortality (aOR 0.93, 95% CI [0.88, 0.99]) and admission to the neonatal unit (0.93 [0.87, 0.98]) significantly decreased over time. Non-invasive ventilation support during stabilisation at birth increased significantly (1.26 [1.15, 1.38]) with corresponding decrease in mechanical ventilation at birth (0.89 [0.81, 0.97]) and following admission (0.80 [0.68–0.96]). Medical treatment for patent ductus arteriosus significantly decreased over the study period (0.90 [0.85, 0.96]). The incidence of major neonatal morbidities remained stable, except for a reduction in late-onset sepsis (0.94 [0.89, 0.99]). Gestation and centre of birth were significant independent factors for several outcomes. The results from our sensitivity analysis were compatible with our main results with the notable exception of death after admission to NICU (0.95 [0.89, 1.01]). There were significant improvements in survival and reduction of late-onset sepsis of extreme preterm infants in South Wales between 2007 and 2016. The sensitivity analysis suggests that some of the temporal changes observed were driven by improved outcomes in the most preterm of infants. Clinical practices related to respiratory support have changed but significant variations in clinical practices and outcomes between centres remain unexplained. The adoption of regional evidence-based clinical guidelines is likely to improve outcomes and reduce variation.

Estimating insertion length of umbilical arterial and venous catheters in newborn infants: time for change

BACKGROUND

Umbilical catheters are inserted through the umbilical artery or vein at birth and are crucial in neonatal care. There are several different methods of estimating adequate insertion length of umbilical catheters based on one of two hypotheses; that the insertion length of the UC is correlated to either the infant's birth weight or an external length measurement.

AIM

To review the published literature on methods of estimating insertion lengths of umbilical arterial catheters (UACs) and umbilical venous catheters (UVCs) in newborn infants.

METHODS

Systematic search on Medline was undertaken using keywords for relevant papers up to March 2019. Papers were selected by manual search of titles and abstracts.

RESULTS

Formulae for predicting umbilical catheter insertion length are unreliable, particularly for UVCs. There is also conflicting evidence around whether birth weight-based formulae are more reliable than external length-based formulae. Studies comparing various methods to determine their efficacy to show that current formulae have a low accuracy for determining both UVC and UAC positioning.

CONCLUSIONS

Current formulae for estimating insertion length of umbilical catheters are not fit for purpose. We propose a new observational study which uses a new external length measurement, the sternal notch to umbilicus length, to develop a more reliable formula for the insertion of UVC and UAC to an adequate length.

Predicting extubation outcomes using the Heart Rate Characteristics index in preterm infants: a cohort study

A strategy of early extubation to noninvasive respiratory support in preterm infants could be boosted by the availability of a decision support tool for clinicians. Using the Heart Rate Characteristics index (HRCi) with clinical parameters, we derived and validated predictive models for extubation readiness and success.Peri-extubation demographic, clinical and HRCi data for up to 96 h were collected from mechanically ventilated infants in the control arm of a randomised trial involving eight neonatal centres, where clinicians were blinded to the HRCi scores. The data were used to produce a multivariable regression model for the probability of subsequent re-intubation. Additionally, a survival model was produced to estimate the probability of re-intubation in the period after extubation.Of the 577 eligible infants, data from 397 infants (69%) were used to derive the pre-extubation model and 180 infants (31%) for validation. The model was also fitted and validated using all combinations of training (five centres) and test (three centres) centres. The estimated probability for the validation episodes showed discrimination with high statistical significance, with an area under the curve of 0.72 (95% CI 0.71-0.74; p<0.001). Data from all infants were used to derive models of the predictive instantaneous hazard of re-intubation adjusted for clinical parameters.Predictive models of extubation readiness and success in real-time can be derived using physiological and clinical variables. The models from our analyses can be accessed using an online tool available at www.heroscore.com/extubation, and have the potential to inform and supplement the confidence of the clinician considering extubation in preterm infants.

Process improvement to effectively manage and reduce sharps injuries in a Tertiary Hospital in Northern India

INTRODUCTION AND OBJECTIVES

Needle stick injuries are associated with a 0.3-30% risk of transmission of Human Immunodeficiency virus, Hepatitis C virus, and Hepatitis B virus. Despite causing psychological trauma they also involve a huge financial burden. A robust process improvement (RPI) toolkit was introduced in order to effectively manage and reduce needle stick injuries, as well as an attempt to report prevalence, post-exposure management, and associated economic burden.

MATERIALS AND METHODS

Prospective Observational Study (2015-2018) has been design in a Corporate Tertiary Care Hospital. The participants included were needle stick injuries exposed staff. RPI toolkit was implemented (2015-2018) focusing on root cause analysis, availability of safety engineered devices, immunization and post-exposure management of needle stick injuries exposed staff. The main outcome measure was needle stick injuries incidence.

RESULTS

A total of 211 needle stick injuries were reported (mean - 52.72/year, needle stick injury incidence - 13.18/year/100 beds). Yearly trends showed a decrease of 21.3% in injuries from 2015 (61) to 2018 (48). Half (106, 50%) of the total injuries were reported among nurses. Use of hypodermic needles was involved in 116 (55%) injuries, with 114 (54%) occurring due to nonadherence to hospital policies. Overall, 204 staff had protective immunity, and 135 (64%) of these had completed their Hepatitis B immunizations. The source was known in 165 (78%) cases, and 113 of these cases had an injury from a source with negative viral markers. A 6-month follow-up was completed in 90 cases. No seroconversion was reported. Overall costs incurred in post-exposure prophylaxis was approximately €30,000 (mean cost €143.50/needle stick injury).

CONCLUSION

Nurses are most at risk of needle stick injury in healthcare settings. Implementation of RPI toolkit led to a 21.3% reduction in sharps injury incidences. These injuries incur huge financial burden on the hospital. Appropriate immunization strategies saved about €1360 expenditure on post-exposure prophylaxis.

Impact of water deficit stress in maize: Phenology and yield components

Fifteen million farmers in India engaged in Maize cultivation. India would require 45 MMT of Maize by 2022. But, only 15% of cultivated area of maize is under irrigation and water shortage has been a challenge for sustainability of maize production. Water deficit stress (WDS) during pre-flowering and grain filling stages massively affects the plant performance due to imprecise traits function. Thus, the effect of WDS on non-drought tolerant (NDT) and drought tolerant (DT) maize lines were investigated. WDS increased the flowering days, days to maturity, anthesis silk interval, decreased the leaf number, abnormal expression of secondary stress responsive traits, loss of normal root architecture which overall lead to a reduction in GY/ha. WDS at flowering and grain filling stage leads to significant yield penalty especially in NDT lines than DT lines. The yield penalty was ranged from 34.28 to 66.15% in NDT and 38.48 to 55.95% in DT lines due to WDS. Using multiple statistics, traits which improve WDS tolerance in maize were identified viz; number of leaves, number of stomata on lower surface of leaf, leaf angle at ear forming node internodal length between 3^rd and 4^th leaf from top, flag leaf length, flag leaf width, ear per plants, leaf senescence, pollen stainability, root fresh weight and root length. These traits would help in trait specific breeding in maize for WDS tolerance.

Antimicrobial effects of different extracts of medicinally used green leafy vegetables collected from local market of Dhaka, Bangladesh

The present study was carried out to determine the antimicrobial efficacy of green leafy vegetable samples which are traditionally used as medicinal herbs. Therefore, three samples each of Neem (Azadirachta indica, leaves), Ivy Gourd (Coccinia grandis, leaves), Water Spinach (Ipomoea aquatica, leaves) and Skunkvine (Paederia foetida, leaves) were collected and subjected to microbiological analysis, and agar well diffusion and microdilution assays to check antimicrobial activity. The samples contained total viable bacteria and fungi up to 107 and 105 CFU/g, respectively. Staphylococcus spp., Klebsiella spp. and Pseudomonas spp. were recovered in all the samples. All the samples showed potential antibacterial activity against most of the tested bacteria, especially their ethanolic and methanolic extracts. Although, crude and hot water extracts almost had no effect on the bacterial growth. The MIC value of the samples was found in a range of 3 mg/mL to 12 mg/mL and the average MIC value was recorded to be 6 mg/mL. Overall, the findings of the present study justified the therapeutic potential of the tested green leafy vegetable samples.

Relationship between Apgar Scores and Morbidity and Mortality Outcomes in Preterm Infants: A Single-Centre Cohort Study

INTRODUCTION

Apgar scoring in modern practice has extended beyond the original described remit by Virginia Apgar, including prognostication. Prognostic value of Apgar scoring in preterm populations is unsupported by robust evidence.

OBJECTIVES

We aimed to identify the association between mortality or a composite mortality/major morbidity outcome in preterm infants with 1-min, 5-min, and sum 1 + 5-min Apgar scores.

METHODS

Seven-year retrospective data was analysed on neonates born <32 weeks gestation in a regional neonatal centre. Co-primary outcomes were mortality and composite mortality/major morbidity. Adjusted odds ratios (aOR) were estimated using multivariable logistic regression analysis.

RESULTS

394 infants were included in the analysis. In neonates born <28 weeks gestation, no significant association was found between Apgar scores and the co-primary outcomes. In neonates born ≥28 weeks, low 1-min (aOR 10.452 [1.273, 85.835] for scores 4-6, 22.173 [2.666, 184.438] for scores 0-3), 5-min (4.724 [1.616, 13.806] for scores 4-6, 11.178 [1.803, 69.299] for scores 0-3), and sum 1 + 5-min Apgar scores (12.447 [2.674, 57.941] for scores 4-6, 55.960 [8.333, 375.804] for scores 0-3) were associated with significantly increased aOR of mortality. Increased aOR of composite mortality/major morbidity were also seen in neonates with moderately low (4-6) Apgar scores (aOR 3.104 [1.522, 6.328] for 1 min, 2.804 [1.406, 5.594] for 5 min, and 3.232 [1.769, 5.905] for 1 + 5 min).

CONCLUSIONS

Apgar scoring at 1 and 5 min has limited prognostic accuracy for extremely preterm infants but is prognostic in older infants. Sum Apgar scores, a measure of initial condition and response to resuscitation, may be a better predictor of mortality than individual scores.

Microsatellite Instability in Chronic Myeloid Leukemia using D17S261 and D3S643 markers: A Pilot Study in Gujarat Population

CONTEXT

Tumor progresses through a series of genetic alterations that involve proto-oncogenes and tumor suppressor genes - the gatekeeper, caretakers, and landscaper genes. Microsatellites are short tandem repeat sequences, present over the span of human genome and are known to be variable at multiple loci due to errors in DNA Mismatch Repair machinery.

AIM

The present study was aimed to evaluate the association between Microsatellite Instability (MSI) and evolution of Chronic Myeloid Leukemia (CML) - genetically a rare event but profound in this pilot study.

SETTINGS AND DESIGNS

We explore the possibility of MSI in primary CML patients confirmed by t(9;22) using capillary electrophoresis. Fifteen CML patients and healthy individual samples, respectively, were used to study the markers D17S261 and D3S643.

MATERIALS AND METHODS

The DNA was amplified using tagged and nontagged primers and further subjected to bioanalysis and fragment analysis.

RESULTS

While the results from bioanalyzer fluctuated, fragment analysis indicated the presence of microsatellite variability in 80% of the patients' samples as compared to no MSI in normal individuals for both the markers.

CONCLUSION

These findings suggest that MSI is a genetic event that may have a role in CML progression or evolution. Further studies are warranted to understand the plausible underlying causes.

Development and characterization of a helicon plasma source

The Helicon Plasma Source (HeliPS) designed and developed at the Centre of Plasma Physics-Institute for Plasma Research is a versatile helicon plasma device, which operates in a wide range of magnetic field configurations from 50 G to 500 G. This device is dedicated to perform a broad range of research activities. The main objective for development of the HeliPS is to carry out studies on ion-ion plasmas in electronegative gases. In the near future, ion-ion plasmas will be formed in electronegative gases in the downstream of the plasma production region. Although the system is primarily designed to carry out ion-ion plasma experiments, the same system can also be used for experimental studies on some basic helicon plasma properties such as wave propagation, wave coupling, and plasma instability. At present, argon plasma is produced with a RF power supply of 13.56 MHz frequency. External circuit parameters, such as antenna current, plasma resistance (R_p), and internal parameters, such as electron density and temperature, are measured. The details of the experimental setup development, device characteristic, as well as preliminary plasma production and characterization to confirm occurrence of the helicon plasma in the system are presented in this article.

Predicting Extubation Outcomes-A Model Incorporating Heart Rate Characteristics Index

OBJECTIVE

To test the hypothesis that in neonates on mechanical ventilation, heart rate characteristics index (HRCi) can be combined with a clinical model for predicting extubation outcomes in neonates.

STUDY DESIGN

HRCi and clinical data for all intended intubation-extubation events (episodes) were retrospectively analyzed between June 2014 and January 2015. Each episode started 6 hours pre-extubation or at the time of primary intubation if ventilation duration was shorter than 6 hours (baseline). The episodes ended at 72 hours postextubation for successful extubations or at reintubation for failed extubations. Mean of 6 hourly epoch HRCi-scores (baseline) or fold-changes (postextubation) were analyzed. Results are expressed as medians (IQR) for continuous data and proportions for categorical data. Multivariable logistic regression mixed model was used for statistical analysis.

RESULTS

Sixty-six infants contributed to 96 episodes (18 failed extubations, 78 successful extubations) in the study. Failed extubations had significantly longer duration of ventilation (65.3 hours, 19.94-158.2 vs 38.4, 16.5-71.3) and more culture positive sepsis (33.3% vs 3.8%) than successful extubations. Baseline HRCi scores (1.68, 1.29-2.45 vs 0.95, 0.54-1.86) and postextubation epoch-1 fold changes (1.25, 0.94-1.55 vs 0.94, 0.82-1.11) were higher in failed extubations compared with successful extubations. Multivariable linear mixed-effects regression was used to create prediction models for success of extubation, using relevant variables.

CONCLUSIONS

The baseline and postextubation HRCi were significantly higher in neonates with extubation failure compared with those who succeeded. Models using HRCi and clinical variables to predict extubation success may add to the confidence of clinicians considering extubation.

Linking AWPS and CARIS data to estimate perinatal mortality in Wales due to congenital anomalies

ABSTRACTObjectivesThe All Wales Perinatal Survey (AWPS) collects mortality data on perinatal, neonatal and infant mortality in Wales up to a year of age. The Congenital Anomaly Register and Information Service (CARIS) collects clinical data on all congenital anomalies in foeti, infants and children in Wales. This was the first attempt to link the AWPS and CARIS databases.ApproachThe AWPS database coded stillbirths, terminations and deaths by the clinic-pathologic classification until 2012, assigning each case a survey number. The CARIS database started collecting data from 1998. Thus, the common period between 1998 and 2012 (15 years) was chosen for this study. Using CARIS as the main dataset, AWPS data were matched against the CARIS database using NHS numbers, along with soft linking on date of birth, maternal date of birth, and postcode. The unique AWPS survey number and coding was then added to the matched record within the CARIS dataset. This final ‘linked’ dataset was used to look at trend data. ResultsBetween 1998 and 2012 a total of 20,574 cases were recorded in the CARIS database. After excluding cases where no gestation or date of death were recorded, and including deaths between >19 weeks’ gestation up to 365 days after birth, there were 1306 foetal losses/terminations, 231 stillbirths, and 662 livebirths (total 2,199) records left in the CARIS database who died with congenital anomalies. In the comparable period, using the same criteria, there were 6,909 records identified in the AWPS database. Of those, 1,765 had a recorded lethal congenital anomaly. By using the above criteria, a total of 2,039 cases in the CARIS database were linked to the AWPS database. 241 cases in the CARIS database and 151 cases in the AWPS database could not be linked by the above methods.Analysing the CARIS cases alone showed that consistently more than 80% of foeti are live-born, and survive. Chromosomal (22%), cardiovascular (21%) and brain (15%) anomalies are the most common congenital anomalies in the linked cases, which contribute to infant mortality. This pattern has remained largely unchanged over the study period. ConclusionUsing NHS numbers and soft linking, the majority of CARIS cases were linked to AWPS cases. Although both these databases should closely reflect each other, missing cases suggest there is scope for improvement in data collection. Sharing of data could also improve the quality of both databases.

A new approach of oral cancer detection using bilateral texture features in digital infrared thermal images

Oral cancer is one of the most prevalent form of cancer and its severity is aggrandized specially among the socio-economically backward population in developing countries. A major fraction of patient population is unable to avail diagnosis for oral cancer due to scarcity of state-of-the-art infrastructure and experienced oral and maxillofacial pathologist. Contemporary gold standard of oral cancer confirmation relies on biopsy report. But biopsy is invasive and thus patients are usually reluctant to undergo this test. Moreover, biopsy yields considerable false negatives if investigated tissue is not collected precisely from the carcinogenic location. Till date, there is dearth of computer aided pre-screening tool for detection of oral cancer. The paper presents Digital Infrared Thermal Imaging as a viable modality for early screening of oral cancer. This is the pioneering attempt to discriminate normal subjects from patients by leveraging discriminating texture features on oral thermograms. Statistically significant texture features were selected from a) both halves of frontal face and b) right and left profile faces. Due to disparity of distribution of facial temperature between normal subjects and patients, the corresponding texture features form discriminative class specific local clusters. Such local conglomeration was exploited using k-means and fuzzy k-means clustering. We adopt the concept of cluster prototype classifier which assigns label to each cluster according to majority class labels within that cluster. Highest classification accuracy of 86.12% is attained on fusion of features from left and right half of frontal face of precancerous subject followed by fuzzy k-means guided cluster prototype classification. The proposed work outperforms our previously developed pre-screening framework by upto 6.5%. Such promising results boosts the viability of our approach.

Agrobacterium-mediated genetic transformation of commercially elite rice restorer line using nptII gene as a plant selection marker

Transformation of commercially important indica cultivars remains challenging for the scientific community even though Agrobacterium-mediated transformation protocols for a few indica rice lines have been well established. We report successful transformation of a commercially important restorer line JK1044R of indica rice hybrid JKRH 401. While following existing protocol, we optimized several parameters for callusing, regeneration and genetic transformation of JK1044R. Calli generated from the rice scutellum tissue were used for transformation by Agrobacterium harboring pCAMBIA2201. A novel two tire selection scheme comprising of Geneticin (G418) and Paramomycin were deployed for selection of transgenic calli as well as regenerated plantlets that expressed neomycin phosphotransferase-II gene encoded by the vector. One specific combination of G418 (30 mg l(-1)) and Paramomycin (70 mg l(-1)) was very effective for calli selection. Transformed and selected calli were detected by monitoring the expression of the reporter gene uidA (GUS). Regenerated plantlets were confirmed through PCR analysis of nptII and gus genes specific primers as well as dot blot using gus gene specific as probe.

Safety and Efficacy of High-Flow Nasal Cannula Therapy in Preterm Infants: A Meta-analysis

BACKGROUND AND OBJECTIVE

High-flow therapy is the most recent, and popular, mode of respiratory support in neonates. However, the evidence supporting its efficacy and safety has not yet been established. We conducted a systematic review and meta-analysis of clinical trials comparing efficacy and safety of high-flow therapy compared with other modes of noninvasive ventilation (NIV) in preterm infants.

METHODS

Articles were indexed by using Medline, Embase, Scopus, OpenSIGLE, Health Management Information Consortium, and Cochrane Central Register of Controlled Trials. Randomized or quasi-randomized clinical trials involving preterm infants, comparing high-flow therapy with other modes of NIV, and reporting extractable data on relevant outcomes, were selected. Data on efficacy, safety, and other common neonatal outcomes were extracted on predesigned forms.

RESULTS

In this analysis, we included 1112 preterm infants, participating in 9 clinical trials. High-flow therapy was similar in efficacy to other modes of NIV in preterm infants when used as primary support (odds ratio of failure of therapy, 1.02 [95% confidence interval: 0.55 to 1.88]), as well as after extubation (1.09 [0.58 to 2.02]). There were no significant differences in odds of death (0.48 [0.18 to 1.24]) between the groups. Preterm infants supported on high-flow had significantly lower odds of nasal trauma (0.13 [0.02 to 0.69]).

CONCLUSIONS

High-flow therapy appears to be similar in efficacy and safety to other conventional modes of NIV in preterm infants. It is associated with significantly lower odds of nasal trauma. Caution needs to be exercised in extreme preterm infants because of the paucity of published data.

Stuve-Wiedemann syndrome with a novel mutation

We describe a female infant born at term to consanguineous parents, with a suspicion of skeletal dysplasia in utero. At birth, she had short limbs, camptodactyly, dysphagia leading to nasogastric tube feeds, and skeletal survey demonstrating dysplasia of long bones and spine. During infancy, she also developed episodes of respiratory failure necessitating admission to intensive care, and periods of hyperhidrosis managed at home. A basic genetic screen did not reveal any abnormalities. Contact was made with the European Skeletal Dysplasia Network, and a provisional diagnosis of Stuve-Wiedemann syndrome was suggested based on this review. Specific genetic tests showed a previously unreported homozygous mutation of leukaemia inhibitory factor receptor gene, confirming the diagnosis. This is the first case with a novel mutation, reported from the UK. For paediatricians and neonatologists, the European Skeletal Dysplasia Network is a valuable resource to reach a specific diagnosis.

Green synthesis of zinc oxide nanoparticles using Hibiscus subdariffa leaf extract: effect of temperature on synthesis, anti-bacterial activity and anti-diabetic activity

Particle size dependent anti-bacterial and anti-diabetic activities of green synthesized ZnO nanoparticles.