The GVK EMRI maternal and neonatal transport system in India: a mega plan for a mammoth problem

Maternal and infant mortality has been a major concern in India with the Government taking serious efforts to achieve the Millennium Development Goals by 2015. Ganapathy Venkata Krishna Reddy Emergency Management and Research Institute (GVK EMRI) is one such effort and is the country's first emergency service provider working under the public-private partnership model to provide emergency response services and quality pre-hospital care to any sick person, pregnant mothers, and sick neonates. Since the introduction of the emergency medical services, institutional deliveries have increased in all states and union territories where the ambulances have been deployed and the majority of mothers have been provided the required emergency care at the appropriate time. This in turn has helped in considerably reducing the maternal mortality. GVK EMRI has partnered with the government of Tamil Nadu and deployed specialized neonatal ambulances to ensure safe transport of newborns. The safe transport of sick, vulnerable neonates and the improvement in survival of transported neonates over the years advocate scaling up of this program to other states, which would greatly contribute towards reducing infant and neonatal mortality.

Ingestion dose from 238U, 232Th, 226Ra, 40K and 137Cs in cereals, pulses and drinking water to adult population in a high background radiation area, Odisha, India

A natural high background radiation area is located in Chhatrapur, Odisha in the eastern part of India. The inhabitants of this area are exposed to external radiation levels higher than the global average background values, due to the presence of uranium, thorium and its decay products in the monazite sands bearing placer deposits in its beaches. The concentrations of (232)Th, (238)U, (226)Ra, (40)K and (137)Cs were determined in cereals (rice and wheat), pulses and drinking water consumed by the population residing around this region and the corresponding annual ingestion dose was calculated. The annual ingestion doses from cereals, pulses and drinking water varied in the range of 109.4-936.8, 10.2-307.5 and 0.5-2.8 µSv y(-1), respectively. The estimated total annual average effective dose due to the ingestion of these radionuclides in cereals, pulses and drinking water was 530 µSv y(-1). The ingestion dose from cereals was the highest mainly due to a high consumption rate. The highest contribution of dose was found to be from (226)Ra for cereals and drinking water and (40)K was the major dose contributor from the intake of pulses. The contribution of man-made radionuclide (137)Cs to the total dose was found to be minimum. (226)Ra was found to be the largest contributor to ingestion dose from all sources.

Spatial distribution of fallout 137Cs in the coastal marine environment of India

The data on the fallout (137)Cs in the coastal marine environment assume significance in view of massive expansion of nuclear power plants in the Asia-Pacific region and to fulfill the benchmark study required to evaluate the possible impact of the Fukushima radioactive releases in the Asia-Pacific region. Measurements of (137)Cs in sea water, along with salinity and temperature, were carried out at 30 locations covering the coastal area of the Arabian Sea and the Bay of Bengal. For the present study the Indian coastal area is divided in three different regions. The (137)Cs concentration in sea water of the entire Indian coastal region varies from 0.30 to 1.25 Bq m(-3). The data obtained in the present study was compared with the North Indian Ocean data and it was observed that there is a 33% decrease in the Arabian Sea (region I), 50% in the high rainfall coastal area (region II) and 24% in the Bay of Bengal (region III).

Differences in thermal adaptation of infants delivered at primary or tertiary care facilities in India

OBJECTIVE

To compare the pattern of thermal stabilization seen in infants born at a rural primary health center (PHC) with that of infants born in an modern urban tertiary care hospital (TCH).

STUDY DESIGN

Abdominal temperature (Ta) and foot temperature (Tf) of healthy term newborn infants were monitored and electronically recorded continuously from birth in the delivery room (DR) until 12 h of life in the postnatal ward (PNW) at two sites. A total of 71 infants were enrolled in the study: 51 infants at the PHC and 20 infants at the TCH.

RESULT

In infants delivered at TCH the maximum mean (±s.d.) Ta of 36.4 ° C ± 0.48 was reached by 12 h, while at PHC maximum mean Ta was 35.4 °C (1.98) by 10.5 h. The mean Tf improved from the lowest value of 29.7 °C ± 1.3 at 4.5 h to 32.9 °C±1.6 by 12 h of life in infants delivered at TCH, whereas in infants delivered at PHC Tf remained low (maximum 30.7 °C) all through 12 h. The mean Td (Ta-Tf) gradually decreased from a maximum of 5.9 °C ± 1.6 at 4.5 h to 3.5 °C ± 1.5 by 12 h of life in infants born at TCH, but the Td remained at >5 °C even after 6 h of life in infants born at PHC, which was statistically significant (P<0.05). The calculated area between the Ta and Tf, a proxy for metabolic stress was greater in babies born at PHC than those born at TCH.

CONCLUSION

Our study shows that although both groups of newborn infants experienced significant thermal stress, infants delivered at PHC experienced significantly greater thermal stress than babies born at TCH. This difference could be attributed to the differences in thermal environment of DR and PNW between PHC and TCH.

Meconium-induced release of nitric oxide in rabbit alveolar cells

Previous studies have shown meconium-induced lung injury occurs throughout release of inflammatory cytokines. The exact mechanism of cytokine-induced apoptosis is not known. In this study we hypothesized that meconium-induced apoptosis in the lungs is mediated through the production of inducible nitric oxide (NO). We studied two groups of newborn rabbit pups: one group was instilled with meconium and other with normal saline. We measured precursors of NO in lung lavage from both groups of rabbits and NO levels were calculated accordingly. The levels of NO and NO-derivatives increased significantly in both groups. However NO expression in meconium group 2 h after meconium instillation was significantly higher than in saline-instilled group suggesting NO production plays a role in meconium-induced inflammation.

Treatment of MAS with PPHN using combined therapy: SLL, bolus surfactant and iNO

The objective of the study was to compare the effectiveness of surfactant treatment either by bolus or surfactant lung lavage followed by inhaled nitric oxide (iNO) therapy in infants with meconium aspiration syndrome (MAS) complicated by persistent pulmonary hypertension (PPHN). In this study, thirteen infants with diagnosis of MAS and PPHN were first treated with conventional respiratory support. Then between 2 and 22h of life they were randomized either to bolus surfactant treatment (n=6) or surfactant lung lavage (SLL, n=7) treatment. Then all infants were treated with iNO therapy. The groups were compared with regard to their clinical course: changes in PaO(2), FiO(2), MAP, OI, A-a oxygen gradient, duration of iNO therapy, length of ventilation and hospitalization. Complications and mortality were also compared. The results showed that infants treated with SLL had significant improvements in oxygenation, decreases in MAP and A-a gradients. But there were no significant differences in duration of ventilation, iNO treatment, length of hospitalization or complications. In conclusion these data show no advantage of SLL therapy over bolus surfactant treatment in infants with MAS complicated by PPHN.

Studies of meconium-induced lung injury: inflammatory cytokine expression and apoptosis

To review current literature related to cellular mechanisms of meconium-induced lung injury (MILI). Review of published experimental in vitro and in vivo MAS studies using human and animal lung cells. We found that meconium induces expression of cytokines and angiotensin II (ANG II)-induced apoptotic process in the lung cells. We postulate that inflammatory cytokines induce ANG II expression, which causes apoptotic cell death after binding to its AT1 receptors. We also demonstrated expression of serpins associated with meconium instillation into the lungs. Serpins are proteins that inhibit cellular proteases and elastases. Expression of serpins may be an attempt to recover lung from these injurious effects. In summary our studies show that whereas meconium induces inflammatory cytokines and subsequent cell apoptosis, the lung cells also try to protect themselves by inducing serpins. The balance of these interactions will determine the residual damage. We believe these new findings are very important in understanding of MILI.

Inflammatory Response and Apoptosis in Newborn Lungs after Meconium Aspiration

An important feature of meconium-instilled newborn lungs is an inflammatory response and apoptotic cell death. It was recently demonstrated by our group and supported by several other investigators in a relatively short period of time. Apoptosis exists also in healthy lungs, but in meconium-instilled lungs its level is usually dramatically higher. Apoptosis is characterized by loss of cell function, decrease in cell size, and its morphology. Apoptosis plays an important role in normal cell life, but increased levels of apoptosis induce great damage for any tissues. Apoptosis in the lungs has been greatly overlooked for the past decade, and meconium-induced apoptosis is a relatively new event and not effectively studied at the present time. This Review summarized current knowledge regarding meconium-induced inflammation and apoptosis in newborn lungs.

Global notes: mysteries of 'the first' and the 'last breath' and the gift of Neonatal Resuscitation Program

First and last breaths define the life span of a living animal including humans. Humans have been fascinated more with the last breath-the death. Neonatologists are focused on initiating the first breath. Millions of babies around the world do not have a chance of survival beyond a few moments after birth for lack of successful initiation of their first breath. Both neonatologists and other health care providers work hard to separate the last breath from the first breath using resuscitative measures thanks to the NRP developed and propagated two decades ago. This paper is dedicated to the initiators of the program, and all those dedicated health care teams working around the globe to save newborn lives.

Global notes: instinctive resuscitation of a newborn by mother: a lesson to be learned

The fact is that mother is the best combined pediatrician and neonatologist in the world. She is the most passionate and vested caregiver for the newborn, whether living and delivering in a modern hospital in a developed country or in a village in the remotest part of the globe; whether she is literate or illiterate. Let us focus our efforts on providing mothers the additional skills in caring for the baby in difficult situations immediately after birth.

Global minute: water and health--walking for water and water wars

Water is a precious commodity and needs to be conserved. Water plays an important role in daily life: in sustenance of life, sanitation and food production. Scarcity of water may lead to water wars among water-stressed nations. Therefore, there is a need for development of democratic principles among nations to assure free access to water to one and all. In view of the fact that lack of access to clean water affects health and infant mortality gap. Great importance is given to improve water resources in the communities (Millennium Development Goal number 7). As professionals entrusted with the health of mother and child, we must strive to improve access to potable clean water to communities in underdeveloped countries.

Global notes: the tale of two giants--China and India

The two giant nations India and China are the emerging powers of the 21st century. There is a debate as to which of the two will edge ahead. This article compares the gains made by the two nations in economics, technology and human development.

Global notes: counting the world's poor--how do we define poverty?

Health professionals are in constant interaction with parents and infants who are victims of poverty and poor socioeconomic status. But an important question remains: do we know how to define poverty? Defining poverty accurately is important as the definition is the basis of policy development. The definition of poverty has changed during the last quarter century. In addition to economic considerations, it is broadened to include other dimensions of life such as literacy, health and longevity. This article attempts to provide national and international definitions of poverty, the magnitude and effects of poverty.

Characterization of serine/cysteine protease inhibitor α1-antitripsin from meconium-instilled rabbit lungs

We have recently purified from meconium-instilled rabbit lungs a novel serine proteinase inhibitor, with an apparent molecular mass of 50 kDa, which we assign to be alpha1-antitripsin. We hypothesize that serpin may attenuate pulmonary inflammation and improve surfactant function after meconium aspiration. Alpha1-antitripsin is a member of the proteinase inhibitor (serpin) superfamily and inhibitor of neutrophil elastase, and it can be identified as a member of the family by its amino acid sequence due to the high degree of conserved residues. Alpha1-antitripsin is synthesized by epithelial cells, macrophages, monocytes, and neutrophils. Deficiency in alpha1-antitripsin leads to exposure of lungs to uncontrolled proteolytic attack from neutrophil elastase or other damaging factors culminating in lung destruction and cell apoptosis. We hypothesize that accumulation of alpha1-antitripsin in the lungs serves as a predisposed protection against meconium-induced lung injury. In this paper, we show how this knowledge can lead to the development of novel therapeutic approaches for treatment of MAS.

Tobramycin and gentamicin are equally safe for neonates: results of a double-blind randomized trial with quantitative assessment of renal function

The frequent use of aminoglycosides in neonates led us to compare tobramycin and gentamicin because some studies in adults and animals suggested a safety advantage for tobramycin. In a randomized, double-blind comparison, 50 infants < or = 3 days old received either tobramycin or gentamicin, 2.5 mg/kg/12 hr, for a mean of 8 days. The groups were similar for gestational age, birth weight, underlying disease, Apgar score, clinical condition, renal function, and concurrent use of other drugs. Trough and postdose serum concentrations of both drugs were similar in each weight group. Renal status at onset, during or up to 2 wk after therapy was also similar, as judged by urinalysis, serum creatinine, fractional excretion of Na, urine N-acetyl-beta-glucosaminidase, and urine to serum creatinine ratio. Nephrotoxicity occurred in four infants (13%) receiving tobramycin and three infants (15%) receiving gentamicin. No otoxicity, as measured by auditory brainstem response, was noted in either group. Tobramycin offered no safety advantages over gentamicin in neonates, and the choice between the agents should be based on other considerations, such as susceptibility of the pathogen and cost.

Cocaine permeability and metabolism in colonic T-84 epithelial cell line

We studied the uptake, transport and metabolism of cocaine in human intestine using the colonic T-84 monolayers as a model. T-84 cells were grown in DMEM/Ham's F-12 medium containing 6% newborn calf serum at 37 degrees C on 1.0 microm collagen inserts. The cells develop into a polarized monolayer with the apical surface facing the upper chamber and the basolateral surface facing the lower. The monolayers develop a transepithelial resistance of > or = 600 ohms cm2 in 7 days. Varying concentrations of cocaine HCI was added in a serum free medium to the luminal side only, and after 30 min and 60 min samples from the luminal and serosal aspect were removed for analysis. Cocaine and its metabolites were measured by GC/MS. Cocaine transport across T-84 monolayers increased linearly with increasing concentration of cocaine, with no significant difference between 30 min and 60 min of exposure. Transepithelial resistance did not change even at 800 ng of cocaine suggesting no effect on monolayer viability. The metabolites, benzoylecgonine (BE) and ecgonine methyl ester (EME) but not norcocaine were detected in both luminal and serosal side. The concentrations of BE and EME in the luminal side were significantly higher than in the serosal. Combined recovery of cocaine, BE and EME from luminal and serosal sides were 52 - 80% of total added cocaine. While fresh medium did not metabolize cocaine, media previously exposed to the monolayer (cell-free medium) caused a significant breakdown into BE and EME, suggesting that esterases may be released into the medium. These results indicate transfer of cocaine across this model of intestinal epithelial cell line is by simple diffusion and is concentration dependent. These studies imply that cocaine in swallowed amniotic fluid can be absorbed by the fetal gastrointestinal tract.

Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India

The impact of a neonatal resuscitation programme (NRP) on the incidence, management and outcome of birth asphyxia was evaluated in 14 teaching hospitals in India. Two faculty members from each institution attended a neonatal resuscitation certification course and afterwards trained staff in their respective hospitals. Each institution provided 3 months pre-intervention and 12 months post-intervention data. Introduction of the NRP significantly increased awareness and documentation of birth asphyxia, as judged by an increased incidence of asphyxia based on apnoea or gasping at 1 and 5 minutes (p < 0.001 and < 0.01, respectively). A significant shift towards more rational resuscitation practices was indicated by a decline in the use of chest compression and medication (p < 0.001 for each), and an increase in the use of bag and mask ventilation (p < 0.001). Although overall neonatal mortality did not decrease, asphyxia-related deaths declined significantly (p < 0.01).

Cell death and lung cell histology in meconium aspirated newborn rabbit lung

Meconium aspiration syndrome (MAS) is a major cause of newborn mortality and morbidity. In this study we investigated the inflammatory responses and morphological changes in the newborn lung to debris-free meconium instillation. We developed a model for studies of MAS using 2-week-old rabbit pups. Cell death was assessed by DNA staining and detection of DNA fragmentation by in situ end labeling. Cell death was seen in association with an increase of inflammatory cytokines levels, studied by ELISA. Necrotic cells were detected by staining of lavage cells with ethidium bromide and 4',6'-diamino-2'-phenylidon. Meconium instillation resulted selectively in loss of airway and alveolar epithelial cells followed by cell death, which increased with time. Necrotic cells looked smaller and damaged with maximal counts at 24 h after instillation.

CONCLUSION

Meconium instillation into lungs caused massive cell death, possibly by apoptosis, and necrosis that may have been activated by the inflammatory cytokine production.

The National Movement of Neonatal Resuscitation in India

Birth asphyxia is an important cause of preventable neonatal morbidity and mortality in developing countries. Of the 26 million births each year in India, 4-6 per cent of neonates fail to establish spontaneous breathing at birth. These babies can be helped, if healthcare professionals present at the time of birth are skilled in the art of neonatal resuscitation. Since the introduction of the Neonatal Resuscitation Programme (NRP) by the American Academy of Pediatrics and American Heart Association, organized training programmes for instructors and providers have been launched in India, under the aegis of the National Neonatology Forum (NNF) since 1990. The initial goal was to train the trainers and provide them with the necessary equipment. The NNF created a national faculty of 150 pediatricians and nurses for NRP by conducting certification courses in various regions of the country. The certified faculty members in turn trained 12,000 healthcare professionals in various parts of India over the following 2 years. Simultaneously, in several teaching institutions, NRP was introduced into the curricula of medical and nursing students. This programme provides a uniform, systematic and action-oriented approach to the resuscitation of the newborn. Prospective evaluation of the resuscitation programme in teaching hospitals has revealed the use of rational resuscitation practices and a significant decline in asphyxia-related deaths.

Use of the Pala-nate device in the prevention of palatal grooves in premature, intubated infants

OBJECTIVE: Previous studies demonstrated that the use of a custom-made intraoral acrylic appliance, known as a palatal stabilizing device, prevents palatal groove formation and reduces the frequency rate of accidental extubations in premature, intubated babies. In this study, we compared the effectiveness of a prefabricated palatal device with an acrylic custom-made palatal stabilizing device. Specifically, we compared the stability, fit, and retention of these two devices. DESIGN: Randomized comparative study. SETTING: Clincal trial. PATIENTS: A total of 70 medically stable, premature, intubated babies. INTERVENTIONS: A total of 70 medically stable, premature, intubated babies randomly received Pala-nate (experimental group, n = 34) or palatal stabilizing device (control group, n = 36). MEASUREMENTS AND MAIN RESULTS: Differences among birth weight, gestational age, and period of intubation of the two groups were statistically nonsignificant at p </=.05. Although both appliances were effective in the prevention of palatal grooves, the Pala-nate was less retentive, thus requiring greater monitoring, and it was associated with a larger number of accidental extubations. The differences between the two groups were statistically significant at p </=.05. CONCLUSIONS: We concluded that the custom-made, acrylic, palatal stabilizing device was more stable and more effective in the prevention of spontaneous extubations in premature orally intubated infants.

Risk of meconium-stained amniotic fluid in different ethnic groups

BACKGROUND

Recent studies indicate that the risk of meconium-stained amniotic fluid (MSAF) varies in different ethnic groups. This study prospectively examined the ethnic variation of MSAF and meconium aspiration syndrome, adjusting for gravidity, gestational age (GA), and birth weight.

METHOD

The study population consisted of 6901 consecutive live births and included 31 different nationalities, seven main ethnic (race) groups, gravidity between 1 and 19, GA between 22 and 44 weeks, and birth weights between 350 and 6292 gm.

RESULTS

The overall incidence of MSAF was 19% (13% thin, 6% thick). The prevalence of meconium aspiration syndrome was 5% in thick MSAF and none in thin MSAF. The incidence of MSAF differs significantly by ethnicity (14% to 30%), gravidity (17% to 23%), GA (6% to 46%), and birth weight (11% to 28%). Multivariate logistic regression analysis using the same variable showed that being black African, post-term, with a gravidity of > or = 7 and a birth weight of > or = 4000 gm significantly increased the chance for MSAF but not meconium aspiration syndrome. After controlling for these clinical variables, the black African infants had a higher percentage of MSAF at all GAs compared with the other ethnic groups.

CONCLUSION

This study showed that the risk of MSAF varied by ethnicity and increased with higher gravidity, a GA of > 42 weeks, and a birth weight of > or = 4000 gm The higher incidence of MSAF without an increase in meconium aspiration syndrome in some ethnic groups may indicate advancing maturity of the gastrointestinal system in black ethnic groups compared with others of the same GA.

Protective effect of lung inflation in reperfusion-induced lung microvascular injury

We used the isolated-perfused rat lung model to study the influence of pulmonary ventilation and surfactant instillation on the development of postreperfusion lung microvascular injury. We hypothesized that the state of lung inflation during ischemia contributes to the development of the injury during reperfusion. Pulmonary microvascular injury was assessed by continuously monitoring the wet lung weight and measuring the vessel wall (125)I-labeled albumin ((125)I-albumin) permeability-surface area product (PS). Sprague-Dawley rats (n = 24) were divided into one control group and five experimental groups (n = 4 rats per group). Control lungs were continuously ventilated with 20% O(2) and perfused for 120 min. All lung preparations were ventilated with 20% O(2) before the ischemia period and during the reperfusion period. The various groups differed only in the ventilatory gas mixtures used during the flow cessation: group I, ventilated with 20% O(2); group II, ventilated with 100% N(2); group III, lungs remained collapsed and unventilated; group IV, same as group III but pretreated with surfactant (4 ml/kg) instilled into the airway; and group V, same as group III but saline (4 ml/kg) was instilled into the airway. Control lungs remained isogravimetric with baseline (125)I-albumin PS value of 4.9 +/- 0.3 x 10(-3) ml x min(-1) x g wet lung wt(-1). Lung wet weight in group III increased by 1.45 +/- 0.35 g and albumin PS increased to 17.7 +/- 2.3 x 10(-3), indicating development of vascular injury during the reperfusion period. Lung wet weight and albumin PS did not increase in groups I and II, indicating that ventilation by either 20% O(2) or 100% N(2) prevented vascular injury. Pretreatment of collapsed lungs with surfactant before cessation of flow also prevented the vascular injury, whereas pretreatment with saline vehicle had no effect. These results indicate that the state of lung inflation during ischemia (irrespective of gas mixture used) and supplementation of surfactant prevent reperfusion-induced lung microvascular injury.

Meconium aspiration syndrome: current concepts and management

Meconium aspiration syndrome (MAS) is a common neonatal problem with significant morbidity and mortality. This article reviews pathophysiology as well as several current approaches to the management of MAS, including high-frequency ventilation and exogenous surfactant replacement, among others.

Cesarean delivery of the breech very-low-birth-weight infant: does it make a difference?

We evaluated the impact of cesarean section (CS) delivery on the outcome of breech very-low-birth-weight (VLBW) (500-1,499 g) infants. This retrospective study used data from a large perinatal data base with 109,428 consecutive deliveries including 1,564 VLBW infants born between 1982 and 1987. The study infants included 982 (62.8%) vertex and 582 (37.2%) breech presentations. The CS rate was higher for the breech group than for the vertex group (72.5% breech, 34.3% vertex, OR 5.1, 95% CI 4.0, 6.4). Breech infants delivered by CS were twice as likely to survive until discharge than those delivered vaginally (breech CS 71.7%, breech vaginal 36.5%, P < .0001). The increased survival with CS for breech presentation (mainly due to fewer deaths on day 1) was not seen with vertex presentation. The CS survival advantage for breech infants was seen in all 250g birth weight subgroups. However, breech VLBW infants delivered by CS had a mean birth weight 233 g more and gestational age 2.1 weeks more than those delivered vaginally. Further, breech infants delivered by CS were more likely to be intubated at birth than vaginally delivered breech infants (OR 4.2, 95% CI 2.0, 5.9). Central nervous system morbidity as measured by the occurrence of seizures and intraventricular hemorrhage was comparable for CS and vaginal infants. Cesarean birth of breech VLBW infants is associated with improved survival. However, breech CS infants were bigger, more mature, and more likely to be intubated at birth than vaginally delivered infants, indicating the presence of a strong selection bias. A prospective randomized trial is needed to evaluate the ideal delivery route for breech VLBW infants.

Racial differences in outcome of pregnancies complicated by hypertension

Racial differences in the outcome of pregnancies complicated by hypertension (HTN) were examined using data obtained from a large perinatal data base with 109,428 consecutive deliveries from 1982 to 1987. Black women had a higher prevalence of hypertension than white women (prevalence ratio 2.3, 95% CI 2.2, 2.5). However, when compared to normotensive women of similar race, white hypertensive women showed a higher risk for adverse pregnancy outcome than black hypertensives as indicated by the higher odds ratio for prematurity (OR: 1.7 for white [W], 1.2 for black [B]), low birth weight (OR: 2.4 W; 1.5 B), intrauterine growth retardation (OR: 4.4 W; 1.6 B) and perinatal death (OR 2.3 W; 1.2 B). Hypertension was associated with a 156 g reduction in birthweight of newborns in whites as compared to a 63 g reduction in blacks. Further studies are needed to understand the racial differences in the impact of HTN on pregnancy outcome.

Endotracheal aspirate cultures in predicting sepsis in ventilated neonates

Nosocomial infections are the most common complications encountered in the neonatal intensive care unit (NICU). They are associated with high mortality and prolonged duration of hospitalization in the survivors, contributing to an increased cost of health care. In this article, we review the literature on the value of routine endotracheal aspirate cultures for the prediction of neonatal sepsis and provide guidelines to prevent nosocomial infections. Upon reviewing the literature it appears that the practice of routine cultures of endotracheal aspirate and cultures obtained from multiple body sites is an expensive proposition with low yield. The sensitivity of this test is at best 50% and all studies report a very low positive predictive value. The specificity of this test is 80%, hence its role is mainly limited to identifying infants who are at low risk for sepsis. As we do not have any reliable test for early diagnosis of neonatal sepsis and also to identify infants at high risk for sepsis, our main emphasis should be towards preventing nosocomial infections. Guidelines for reducing nosocomial infections are described.

Bile flow and composition in preterm, term and infant baboons

We studied the maturational changes in bile composition, bile flow and choleretic effects of sodium taurocholate and secretin in preterm (160 +/- 2 days, n = 4, group I), term (184 +/- 2 days, n = 4, group II), 7-day postnatal age (n = 5, group III) and 60-day-old (n = 5, group IV) baboons. The canalicular bile flow was determined by 14C-erythritol clearance.

RESULTS

Gall bladder volume increased from group I to group III (0.08 +/- 0.06 to 1.06 +/- 0.93 ml). Bile flow increased significantly from group I to IV (0.13 +/- 0.05 to 0.34 +/- 0.07 microliter/min/g liver weight, p < 0.05). This was associated with significant increases in total bile acid excretion (16 +/- 3.6 to 31 +/- 2.5 mEq/l, p < 0.05). The composition of bile also showed maturational changes with increasing postnatal age. Sodium taurocholate and secretin increased the bile flow significantly in all groups.

CONCLUSION

Data from these studies clearly demonstrate that the bile flow and bile acid excretion is immature in preterm and term baboons when compared to 7- and 60-day-old baboons. The present studies also suggest that baboons can be used as a model to study the postnatal maturation of hepatic excretory function.

Pharmacokinetics of once-daily dosing of gentamicin in neonates

In a prospective, randomized trial of once-daily versus twice-daily intravenous or intramuscular dosing with gentamicin, 11 neonates received 5.0 mg/kg once daily and 15 received 2.5 mg/kg twice daily for 2 ro 3 days. The once-daily intravenous dosing group and the twice-daily intravenous or intramuscular dosing group, respectively, had mean steady-state gentamicin peak concentrations of 10.7 versus 6.6 micrograms/ml (p < 0.05), 6-hour postdosing concentrations of 4.7 versus 2.8 micrograms/ml (p < 0.05), trough concentrations of 1.7 versus 1.7 micrograms/ml, elimination half-life of 8.8 versus 5.4 hours (p < 0.05), and volume of distribution at steady state of 0.67 versus 0.46 L/kg. No nephrotoxic effects were identified in any group. Once-daily gentamicin therapy with 5.0 mg/kg in neonates achieves peak serum levels that are more suitable for optimal bacterial killing than those which traditional regimens achieve. Similar trough levels suggest that even larger doses and longer dosing intervals may be ideal in term neonates.

Mechanics and energetics of nutritive sucking: a functional comparison of commercially available nipples

The purpose of this study was to compare the mechanics of sucking for 48 term infants with four different nipple units: Gerber Newborn (Gerber Products Company, Fremont, Mich.), Playtex (Playtex Products, Westport, Conn.), Evenflo (Evenflo Products Co., Canton, Ga.), and Gerber NUK. At 24 hours after birth, infants were assigned randomly to one of the nipple units and were studied twice with that nipple unit. A customized data acquisition system was used to measure and record the following variables: intraoral suction, sucking frequency, work, power, milk flow, milk volume per suck, and oxygen saturation. Although no statistically significant differences among the nipple units were noted for intraoral suction, sucking frequency, power, and oxygen saturation, the data revealed that the Playtex nipple unit was accompanied by higher peak milk flow and greater volume of milk per suck (p < 0.05). Infants fed differently with the Playtex nipple than they did with the other nipples. Our findings indicate that the Playtex nipple permits a greater milk flow in response to similar amounts of suction, work, and power when compared with others. The mean total work per such was significantly lower in the Gerber NUK group compared with the Playtex group. In addition, the total number of sucks per volume ingested was higher, and the total time to ingest a specific quantity of milk was longer for the Gerber NUK nipple.

Critical care in India

India is a vast democracy of nearly one billion people. Before the British rule ended in 1947, the life span of an Indian was a mere 21 years. Within a short span of 50 years, it increased to an impressive 63 years, largely due to public health measures initiated by the government. This created a pool of more than 300 million middle class Indians who could afford the benefits of modern and specialized care when needed. Critical care medicine, as practiced in the West, is still confined to large Metropolitan areas. A large pool of expatriate Indian physicians from all over the world are helping bridge the resource gap between the West and India by transfer of technology and providing appropriate training to physicians and paramedical personnel. This article describes the history and current status of development of critical care medicine 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.

Chloride transport in primary cultures of rabbit colonocytes at different stages of development

BACKGROUND & AIMS

Ontogeny of colonic Cl- transport and its regulation has been characterized inadequately. The aim of this report was to study developmental changes in Cl- transport in primary cultures of rabbit distal colonocytes.

METHODS

Colonocytes from newborn (7-9 days old), weanling (25-28 days old), and adult (6 months old) rabbits were cultured for 24 hours on a collagen IV matrix, and Cl- transport was measured using the fluoroprobe 6-methoxyquinolyl acetoethyl ester.

RESULTS

Cl- permeabilities were dependent on [Cl-]o with maximal rates (in millimoles per liter per second) at [Cl-]o = 75 mmol/L (newborns; 0.15 +/- 0.04; weanlings; 0.2 +/- 0.02; and adults, 0.32 +/- 0.06). Influx was inhibited significantly by the Cl- channel (50 mumol/L diphenylamine-2-carboxylate) and the Na(+)-K(+)- 2Cl- cotransport (10 mumol/L furosemide) inhibitors. The adenosine 3',5'-cyclic monophosphate (cAMP)-dependent secretagogues, prostaglandin E1 (1 mumol/L), forskolin (1 mumol/L), and 8-bromo-cAMP (100 mumol/L), and the protein kinase C activator, phorbol 12-13 dibutyrate (1 mumol/L), increased Cl- influx significantly in all groups with adults showing greatest stimulation. However, taurodeoxycholate (0.025-1 mmol/L) had an effect only in the adult and the guanosine 3',5'-cyclic monophosphate (cGMP) activators STa and 8-bromo-cGMP had no effect.

CONCLUSIONS

Rabbit distal colonocytes possess inhibitor-sensitive Cl- permeabilities even in neonates. However, the ontogeny of their regulation depends on the secretagogue-signaling pathway.

Vitamin A deficiency and severe bronchopulmonary dysplasia in very low birthweight infants

Preterm infants often have abnormally low serum vitamin A concentrations. Persistence of vitamin A deficiency for a prolonged postnatal period may contribute to the development of bronchopulmonary dysplasia. We retrospectively analyzed data from 22 infants with birthweight < or = 1250 g who had hyaline membrane disease requiring mechanical ventilation with oxygen and in whom serum vitamin A concentrations had been measured at the onset of enteral feeding and every 2 weeks thereafter. Thirteen infants (low serum vitamin A group) had one or more serum vitamin A concentrations < or = 11 mcg/dL at > 10 days of age. In 9 infants (higher serum vitamin A group) all serum vitamin A concentrations were > 11 mcg/dL at > 10 days of age. Mean birthweight, mean gestational age, sex, race, incidence of antenatal maternal glucocorticoid treatment and ventilatory support on the first day of life were similar for the two groups. Severe bronchopulmonary dysplasia was as defined as characteristic radiographic changes and either discharge from the hospital with supplemental oxygen or death from respiratory failure at > 28 days of age following mechanical ventilation with oxygen since birth. The incidence of severe bronchopulmonary dysplasia was significantly higher in the low serum vitamin A group (11/13, 3 deaths vs. 1/9, no deaths; p=0.001). The incidence of pulmonary air leak, the number of ventilator days, the number of days of postnatal glucocorticoid treatment for chronic lung disease, the number of episodes of suspected sepsis and the number of days of antibiotic treatment also were higher in the low serum vitamin A group. Low serum vitamin A group infants were older at the onset of enteral feeding (21 days vs. 8 days; p = 0.001) and during feeding their average daily enteral intake of vitamin A was lower (713 IU vs. 1255 IU; p = 0.001) when compared with infants in the higher serum vitamin A group. Our retrospective analysis of data from these infants confirms earlier reports from other workers that persistent marked vitamin A deficiency in very low birthweight infants is associated with a high incidence of severe bronchopulmonary dysplasia, delayed onset of enteral feeding and low enteral intake of vitamin A.

Altered growth and attachment of rabbit crypt colonocytes isolated from different developmental stages

The rabbit colon was used to establish an in vitro model for examining development-related cellular changes in colonocyte function. Colonic epithelia from newborn, weanling, and adult animals were separated from the muscle and subjected to enzymatic digestion. A mixture of 0.05% Pronase, 0.015% collagenase IV, and 0.023% DTT was determined to be optimal for the isolation of newborn and weanling colonocytes. This solution yielded significantly more cells and of greater viability than a 0.1% Pronase, 0.03% collagenase IV, 0.07% DTT mixture that is optimal for adult colonocytes. The epithelial origin of the colonocytes was confirmed by immunofluorescent staining of cytokeratins. The isolation procedure resulted in a crypt-enriched population and the cell yield/g of mucosa increased with age as did the crypt depth. Colonocyte viability of adults but not of newborns and weanlings, declined from 24 to 72 h. When grown on plastic, the newborn and weanling colonocytes show a approximately 2-fold increase in number, DNA and protein content over 48 h. In contrast, for all three parameters the adult colonocytes revealed only a approximately 10% increase. The colonocytes also showed an age-related decline in attachment to extracellular matrices. Colonocytes showed maximal attachment to Matrigel and collagen IV; newborn and weanling colonocytes show > 80% attachment, whereas adult colonocytes showed only a 45% attachment. The efficacy of attachment to Matrigel compared with that on plastic also differed with age, representing 9.3-, 5.5-, and 4.4-fold increase in adult, weanling, and newborn colonocytes, respectively. Newborn and weanling colonocytes grown on Matrigel for 48 h, showed a significant, 15% increase in cell number, DNA, and protein content compared with those grown on plastic. There was no difference in these parameters when adult colonocytes grown on Matrigel were compared with those grown on plastic. In summary, we have established an in vitro model for studying colonic epithelial cells at different stages of development.

Renal actions of endothelin-1 in newborn piglets: dose-effect relation and the effects of receptor antagonist (BQ-123) and cyclooxygenase inhibitor (indomethacin)

Although the effects of endothelin-1 (ET-1) on intact or perfused adult kidney are well understood, its effects in the fetus and the newborn have not been well studied. We examined the effects of infusions of 25, 50, and 100 ng/kg of ET-1 per minute on mean blood pressure (MBP), cardiac index (CI), renal blood flow (RBF), glomerular filtration rate (GFR), and urine volume (UV) in 7- to 10-day-old piglets (n = 24). In addition, the effects of pretreatment with a receptor antagonist (BQ-123) and with a cyclooxygenase inhibitor (indomethacin) were studied in 12 separate piglets. ET-1 produced a dose- and level-dependent decrease in CI (60%), RBF (50% to 75%), GFR (66% to 80%) and MBP 15% to 17%. These changes returned to 75% to 80% of baseline 60 minutes after discontinuation of ET-1. Low-dose infusion (25 ng/kg) did not result in any changes in systemic or renal hemodynamics. Plasma half-life of ET-1 in piglets was 2.1 +/- 0.4 minutes. Pretreatment with the specific ETA receptor antagonist BQ-123 completely blocked the ET-1-induced systemic and renal hemodynamic changes. Indomethacin blocked the ET-1-induced rise in MBP but failed to block any renal changes. In fact, indomethacin accentuated the changes induced by ET-1, especially the changes in RBF, RVR, and GFR. Studies of receptor binding in the renal cortex and medulla showed that, in the cortex, the Ki value for ET-1 was 6.32 +/- 1.57, and for ET-3 it was 20.05 +/- 4.38 (p < 0.05); in the medulla, the Ki values were similar for both ET-1 and ET-3. These results indicate that in piglets the renal vascular bed is highly sensitive to ET-1, and its effects are predominantly mediated through ETA receptors.

Changes in the concentration of endothelin-1 during development of hypertensive rats

The concentration of endothelin-1 (ET-1) in the brain regions, heart, and throacic aorta of 1-, 4-, 6- and 8-week-old spontaneously hypertensive (SHR) and normotensive Wistar-Kyoto (WKY) rats was determined using radioimmunoassay. ET-1-like immunoreactivity in the brain regions of 1-week-old WKY and SHR rats was lower compared to older (6 and 8 weeks) rats. ET-1 levels in the central nervous system gradually increased with age in both SHR and WKY rats. However, the concentration of ET-1 in 8-week-old rats was lower in the brain regions of SHR compared to WKY rats. The concentration of ET-1 in the thoracic aorta of SHR (224 +/- 43 pg/g tissue) rats was lower than that of WKY (452 +/- 11 pg/g tissue) rats at 1 week of age. However, ET-1 levels gradually increased with age in SHR rats. By 8 weeks of age, levels of ET-1 in SHR (623 +/- 33 pg/g tissue) rats were higher compared to WKY (439 +/- 62 pg/g tissue) rats. In the heart, ET-1 levels were similar in WKY and SHR rats at 4 weeks of age, but at 8 weeks of age ET-1 levels were higher in SHR rats (364 +/- 33 pg/g tissue) compared to WKY rats (260 +/- 31 pg/g tissue). It appears that at 8 weeks of age when hypertension is fully expressed in rats, ET-1 levels are lower in the central nervous system and are higher in the thoracic aorta and heart of SHR compared to WKY rats.