The impact of certificate of need programs on neonatal intensive care units

OBJECTIVE

To determine the impact of state certificate of need programs (CON) on the number of hospitals with neonatal intensive care units (NICU) and the number of NICU beds.

STUDY DESIGN

The presence of a CON program was verified from each state's department of health. Multivariable regression models determined the association between the absence of a CON program and each outcome after controlling for socioeconomic and demographic differences between states.

RESULT

A total of 30 states had CON programs that oversaw NICUs in 2008. Absence of such programs was associated with more hospitals with a NICU (Rate Ratio (RR) 2.06, 95% CI 1.74 to 2.45) and NICU beds (RR 1.96, 95% CI 1.89 to 2.03) compared with states with CON legislation, and increased all-infant mortality rates in states with a large metropolitan area.

CONCLUSION

There has been an erosion of CON programs that oversee NICUs. CON programs are associated with more efficient delivery of neonatal care.

Transmyocardial laser revascularisation combined with coronary artery bypass grafting without cardiopulmonary bypass

OBJECTIVE

To achieve complete myocardial revascularisation in patients with diffuse coronary artery disease, patients with inordinately high risk of cardiopulmonary bypass (CPB) like severe systemic disease or diffuse atherosclerosis of the aorta.

METHODS

We have adopted the technique of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) using 1000 W CO2 laser machine. TMLR is done to areas supplied by ungraftable arteries, while CABG without cardiopulmonary bypass is done to the left anterior descending artery (LAD) and/or right coronary artery (RCA). TMLR + CABG on beating heart without CPB has been performed on 56 patients. Age ranged from 37 to 81 years with a mean of 56.17. Four patients were in renal failure, two were redo CABG. Preoperatively 39.28% patients had angina class III and 10.71% had angina class IV. Four patients were on preoperative IABP support.

RESULTS

The mean number of grafts was 1.09. Internal thoracic artery (ITA) was used in 96.4% of the patients. Five patients showed elevation of CPK-MB, while three patients had an increase in Troponin T. Mortality was 1.8% (one patient died of intractable ventricular arrhythmia). The mean follow-up is 9.2 months. Myocardial perfusion scanning showed a stepwise improvement in reversible ischemia increasing from 52% at baseline to 91% at 12 months; 90.9% of the patients were angina free at 12 months. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 min at baseline to 9.4 min at 12 months. Metabolic equivalents (METs) increased from 4.5 at baseline to 9.4 at 12 months. The average 44% Karnofsky score preoperative also increased to 86% at 12 months.

CONCLUSIONS

Our results indicate that the technique is surgically feasible and safe, with excellent short term results.

Epidemiology and outcome of sepsis in a tertiary care PICU of Pakistan

OBJECTIVE

To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital.

METHODS

Retrospective review of children 1 mo to 14 y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression.

RESULTS

In 2 years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18 mo (IQR 6-93 mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2-144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6-4.0) and the need for > 2 inotropes (Adjusted OR 3.5, 95% CI 1.3-9.2) were independently associated with mortality due to sepsis.

CONCLUSIONS

The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.

Secondary fractures of Le Fort I osteotomy

PURPOSE

To report the ophthalmic complications of Le Fort I osteotomy for the correction of dentofacial deformities and to determine the maximal compressive loads applied during pterygomaxillary separation in a cadaver model.

METHODS

Two cases of ophthalmic complications arising after Le Fort I osteotomy are reported. Le Fort I osteotomy was performed on five cadavers. The maximal compressive load applied during pterygomaxillary separation was recorded with a 10 kN (3,000 lbf) load cell of a MTS Mini-Bionix servo-hydraulic machine (MTS, Eden Prairie, MN, U.S.A.). A paired t test was used to compare forces applied to the right and left sides. Computed tomography scans of each specimen were obtained after Le Fort I osteotomy to document secondary fractures. The skulls were subsequently stained with 1% fuschin red to highlight secondary fractures.

RESULTS

Maximum compressive loads during pterygomaxillary separation ranged from 22 N (5.0 lbf) to 162 N (36.5 lbf), with an average of 106 N (23.8 lbf) (SD 47.6 N [10.7 lbf]). Forces applied on the first operative side were significantly greater than forces applied on the second operative side (p = 0.0034). Secondary fractures were found in three specimens by computed tomography and in two specimens by 1% fuschin red. All secondary fractures occurred on the second operative side.

CONCLUSION

Secondary fractures in the Le Fort I osteotomy procedures occurred on the side opposite the greater maximal compressive load and on the second operative side.

Mechanical strength of fracture callus in osteopenic bone at different phases of healing

OBJECTIVES

To quantify and compare peak bending force and stiffness of fractured femurs during healing of ovariectomized (OVX) and sham-operated (SHAM) rats.

DESIGN

Temporal biomechanical animal study.

SETTING

Rat femurs were fractured and surgically fixed by a qualified surgeon. The inherent instability of the fixation system employed produced delayed union of the fracture. All biomechanical assessments were performed with servohydraulic test machines (Instron Inc., Canton, MA, U.S.A.; and MTS Corp., Eden Prairie, MN, U.S.A.).

INTERVENTION

OVX was performed sixteen weeks before femur fracture, and the effect of OVX on healing fractures was determined.

MAIN OUTCOMES

Peak bending force and stiffness of the healing femurs at four, six, and eight weeks after fracture.

RESULTS

Peak bending loads of the healing fractured femurs in the OVX and SHAM animals were not significantly different. Peak bending loads for the OVX animals at four and six weeks were significantly lower than the peak load at eight weeks (p < 0.05), whereas no difference was found in the peak load with respect to time for the SHAM animals. Both SHAM and OVX animals had greater bending stiffness of the healing fractured femur after eight weeks of healing than at four weeks (p < 0.05).

CONCLUSIONS

OVX is known to reduce cancellous bone mass and strength, but the effect of OVX on healing of fractures in cortical bone is controversial. This study, using a delayed-union model, found no significant differences between OVX and SHAM animals in the breaking strength of healing fractures.

Pneumothoraces in a neonatal tertiary care unit: case series

OBJECTIVE

Neonatal pneumothoraces are associated with high mortality. Prompt recognition to minimize its complications is paramount for ultimate outcome of these babies.

METHODS

A retrospective case series study was carried out at Aga khan University Hospital, from January 2010 to December 2010 to determine the etiology and outcome of neonates with pneumothorax in a neonatal tertiary care unit.

RESULTS

Ten neonates diagnosed radiologically with pneumothoraces were included. M: F ratio was 1:2.3. Birth weight ranged from 1750-3600 grams with a mean of 2100 grams. The occurrence of pneumothoraces was 50% on the left side, 20% on right, and 30% were bilateral. Primary etiology included pneumonia and sepsis (30%), hyaline membrane disease (20%), meconium aspiration syndrome (20%) and congenital diaphragmatic hernia (10%). Spontaneous pneumothoraces were present in 20% of cases. In our study, the incidence of neonatal pneumothoraces was 2.5/1000 births compared to 10-15/1000 in Denmark, 10-20/1000 in Turkey and 6.3/1000 from Vermont Oxford Group. Despite the small number of cases, one incidental finding was the occurrence of pneumothorax, which declined in elective cesarean section after 37 weeks gestation i.e., 1.3 of 1000 births. Mortality was 60% determined mainly by the primary etiology and other co-morbid conditions.

CONCLUSION

The study showed a higher number of mortality cases (60%). Although, it was difficult to draw a conclusion from the limited number of cases, there may be a benefit on neonatal respiratory outcome to be obtained by better selection of mothers and by waiting until 37 weeks before performing elective cesarean section. Adequate clinician training in soft ventilation strategies will reduce the occurrence of pneumothoraces.

Evaluation of an automated fetal myocardial performance index

OBJECTIVE

To compare automated measurements of the fetal left myocardial performance index (MPI) with manual measurements for absolute value, repeatability and waveform acceptability.

METHODS

This was a multicenter international online study using images from uncomplicated, morphologically normal singleton pregnancies (16-38 weeks' gestation). Single Doppler ultrasound cardiac cycle images of 25 cases were selected, triplicated and randomized (n = 75). Six senior observers, unaware of the repetition of images, manually calculated MPI for each waveform and the results were compared with automation. Intraobserver repeatability and interobserver reproducibility were assessed using intraclass correlation coefficients (ICCs) and 95% CI. The agreement between each observer's manual MPI measurements and corresponding automated measurements was evaluated using Bland-Altman plots and ICCs with 95% CI. The degree of variation between experts in the classification of fetal MPI waveform quality was assessed using individual cardiac cycle left MPI images previously classified by two authors as 'optimal', 'suboptimal' or 'unacceptable', with 30 images selected for each quality group. Ten images in each category were duplicated and the resulting 120 images were randomized and then classified online by five observers. The kappa statistic (κ) was used to demonstrate interobserver and intraobserver agreement and agreement of classifications by the five observers.

RESULTS

The automated measurement software returned the same value for any given image, resulting in an ICC of 1.00. Manual measurements had intraobserver repeatability ICC values ranging from 0.69 to 0.97, and the interobserver reproducibility ICC was 0.78. Comparison of automated vs manual MPI absolute measurements for each observer gave ICCs ranging from 0.77 to 0.96. Interobserver image quality classification agreement gave k = 0.69 (P < 0.001), and the intraobserver agreement was variable (κ ranging from 0.40 to 0.81).

CONCLUSIONS

Automated fetal MPI provides superior repeatability and reproducibility to manual methodology. Additionally, experts vary significantly when classifying suitability of fetal MPI waveforms. Automated MPI may facilitate clinical translation by removing human subjectivity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Market assessment of tuberculosis diagnostics in India in 2013

BACKGROUND

India represents a significant potential market for new tests. We assessed India's market for tuberculosis (TB) diagnostics in 2013.

METHODS

Test volumes and unit costs were assessed for tuberculin tests, interferon-gamma release assays, sputum smear microscopy, serology, culture, speciation testing, nucleic-acid amplification tests (i.e., in-house polymerase chain reaction, Xpert(®) MTB/RIF, line-probe assays) and drug susceptibility testing. Data from the public sector were collected from the Revised National TB Control Programme reports. Private sector data were collected through a survey of private laboratories and practitioners. Data were also collected from manufacturers.

RESULTS

In 2013, India's public sector performed 19.2 million tests, with a market value of US$22.9 million. The private sector performed 13.6 million tests, with a market value of US$60.4 million when prices charged to the patient were applied. The overall market was US$70.8 million when unit costs from the ingredient approach were used for the 32.8 million TB tests performed in the entire country. Smear microscopy was the most common test performed, accounting for 25% of the overall market value.

CONCLUSION

India's estimated market value for TB diagnostics in 2013 was US$70.8 million. These data should be of relevance to test developers, donors and implementers.

Beat-to-beat variability of fetal myocardial performance index

OBJECTIVES

To determine whether there is beat-to-beat (BTB) variability in the fetal left myocardial performance index (MPI), as evaluated by an automated system, and whether there is a correlation between MPI and fetal heart rate (FHR).

METHODS

This was a prospective cross-sectional study of uncomplicated, morphologically normal, singleton pregnancies at 20-38 weeks' gestation. Multiple cineloops for left MPI measurement were acquired during a single examination of each fetus. Raw cineloop data were analyzed by our automated MPI system (intraclass correlation coefficient of 1.0 for any given waveform) to produce a set of MPIs. The corresponding instantaneous FHR was measured for each individual cardiac cycle for which MPI was calculated.

RESULTS

Data from 29 fetuses were analyzed; mean MPI was 0.52, mean FHR was 150 beats per min and the median number of cardiac cycles examined per fetus was 70 (interquartile range, 31-115). Marked BTB variability was noted; median coefficient of variation was 10% (range, 5.5-13.9%). FHR was weakly correlated with absolute MPI (r = 0.22; P < 0.05). BTB variation in MPI as a percentage of the mean MPI was not significantly correlated with FHR (r = 0.031; P = 0.146). When standard error of the mean of all MPI values was divided by the mean for each case, it showed that at least four cardiac cycles should be averaged to reduce MPI variability to approximately ± 5%.

CONCLUSION

There is significant BTB variability in fetal left MPI, which has an overall weak correlation with FHR. This could be a factor affecting the consistency of MPI values reported by different research groups. Variability would be reduced by averaging 4-5 cardiac cycles per fetus. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Antidiabetic activity of methanolic extract of Hiptage bengalensis leaves in alloxan induced diabetic models

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia and its occurrence is increasing fast in most of the countries. Herbal medicine derived from plant extracts have been utilized increasingly for the treatment of various disorders like diabetes mellitus. The present study was designed to evaluate the antidiabetic activity of Methanolic Extract of Hiptage bengalensis L. Kurz (MEHB) in alloxan induced diabetic rats and chick model. Alloxan (120 mg kg-1) was used to induce diabetes in rats and the blood glucose levels were estimated by using commercial kit in the market. The methanolic extract of Hiptage bengalensis was administered to diabetic rats as single dose for one day at a dose of 100 and 200 mg kg-1. The extract produced a significant reduction (p<0.01) of blood glucose levels at a dose of 100 and 200 mg kg-1 in diabetic rats. It also showed a beneficial effect on the lipid profile in alloxan induced diabetic rats. These results showed that methanolic extract of Hiptage bengalensis produced a dose dependant antihyperglycemic activity in rats.

Evaluation of the efficacy of simplified Fencl-Stewart equation in analyzing the changes in acid base status following resuscitation with two different fluids

Background:

Metabolic acid-base disorders in critically ill patients may not be identified by base excess (BE) approach. Anion gap method can detect approximately 1/3 hidden “gap acidosis”. In such conditions, when adjusted for hypoalbuminemia, Fencl-Stewart's approach can reliably detect the hidden abnormal anions.

Aim:

Evaluate the efficacy of simplified Fencl-Stewart equation in identifying the changes in acid-base status of sepsis patients following resuscitation with two different fluids.

Settings and Design:

Intensive care unit, randomized, prospective, interventional study.

Materials and Methods:

Three hundred adult patients of both sexes presenting with abdominal sepsis, requiring fluid resuscitation were randomly assigned into normal saline (NS) and Ringer's lactate (RL) group, each comprising of 150 patients. 20 ml/kg of NS or RL were administered over a period of 30 min. The changes in the acid-base status were calculated applying the simplified Fencl-Stewart equation and was compared with the measured values obtained through arterial blood gas.

Statistical Methods:

Paired t-test for intra-group while unpaired t-test for inter-group comparison.

Results:

Blood pH and standard BE decreased and the serum Na⁺ and Cl^- level increased significantly in NS group. The serum albumin level significantly decreased in both the groups. Sodium chloride effect on BE significantly increased in NS group. Albumin effect on BE significantly increased in both the groups. Unmeasured ion effect on BE did not significantly change in both the groups. Measured standard BE level was significantly less as compared to unmeasured anion effect on BE, in both the groups.

Conclusion:

Simplified Fencl-Stewart equation is effective in identifying a mixed acid-base disorder, which otherwise would remain undetected.

Acute necrotizing encephalopathy of childhood: a fatal complication of swine flu

Acute necrotizing encephalopathy of childhood (ANEC) is a rare condition characterized by the presence of multifocal symmetrical brain lesions involving mainly thalami, brainstem, cerebellum and white matter. ANEC is a serious and life threatening complication of simple viral infections. We present a case of a young child who developed this condition with classical clinical and radiological findings consistent with ANEC, secondary to swine flu (H1N1). He needed ventilatory support and had profound motor and intellectual deficit on discharge. We report this case with aim of raising awareness about this fatal complication of swine flu which has become a global health care issue these days.

Readmission to paediatric intensive care unit: frequency, causes and outcome

Readmission to intensive care units is considered to be an important quality indicator in ICU settings. This study was carried out at the paediatric intensive unit (PICU) and step down units of paediatric ward at the Aga Khan University Hospital, Karachi, Pakistan, to assess the frequency, common causes and outcome of patients readmitted in PICU within 48 hours after discharge from unit. During the study period, 1022 patients were admitted in PICU, out of which 24 (2.34%) patients required readmission. Male to female ratio was 1.2:1. The mean length of stay on paediatric floor before readmission was 24 hours. Fifteen (62%) patients were readmitted due to worsening of primary condition while 9 (38%) developed new problems. Respiratory problems accounted for 15 (62.5%) of readmissions, followed by cardiovascular 4 (16.5%) and sepsis related causes 3 (12.5%). The mortality rate of readmitted patients was 21% (5/24) in this study as compared to overall PICU mortality of 122 (11.93%).

Private sector hospital response to the 2003 dengue outbreak in the Indian capital metropolis of Delhi

During 2003, the Indian capital metropolis of Delhi was afflicted with an outbreak of dengue. A private-sector tertiary care hospital responded instantly to the sudden influx of 162 patients during an 8-week interval. That was an unusual challenge because, until 1997, the hospital had exclusively managed patients with ophthalmic disorders. Dengue patients received fiscal concessions and several free services. A multidisciplinary cell was commissioned for case management. Apart from a diagnosis of patients with dengue and their clinical management, suspected or confirmed dengue episodes were instantly reported to health authorities. Anti-mosquito measures in the hospital premises including residential areas for the nursing personnel prevented any local virus transmission. The integrated therapeutic and public health response was associated with a 1.23% case fatality rate. The protocol developed during the dengue outbreak would address every locally reportable disease in the future.

Elective tracheostomy in mechanically ventilated children

Tracheostomy is an important procedure in children requiring prolonged mechanical ventilation. We conducted a retrospective study to assess the frequency, indications, postoperative course and short-term outcome of elective tracheostomy in a Paediatric Intensive Care Unit (PICU) of Pakistan. Twenty-five patients underwent tracheostomy in last 5 years (2.2 % of all PICU admissions). Mean age of patients was 6 years and 60% were male. The most common indication for tracheostomy was prolonged mechanical ventilation secondary to neurological disease (60%), followed by upper airway obstruction (40%). Major complications included accidental decannulation (20%) and tube obstruction (20%). Three patients (12%) developed ventilator-associated pneumonia after tracheostomy change while persistent bacterial colonization of trachea was observed in 8 patients (32%). Decannulation was achieved in 40% (10/25). There was no mortality related to tracheostomy in this series.

Detection of S-100 protein and anticeramide antibodies in leprosy patients by ELISA

The status of assay for S-100 antigen protein and anticeramide antibodies in serum in understanding nerve damage in different forms of leprosy were evaluated by the enzyme immunoassay. Based on the clinical and smear examination, patients were classified as indeterminate (Ind), tuberculoid (TT), borderline tuberculoid (BT), borderline lepromatous (BL) and lepromatous (LL). Antibody levels against ceramide were observed in sera of leprosy patients with 37.5% of Ind, 28% of TT, 66% BT, 78% BL and 62% LL patients positive as against 8% endemic normal sera. The mean OD ranged from 0.141 to 0.275 in different groups of leprosy. In contrast, S-100 was detected in 71.4% Ind, 88.8% TT, 76.4% BT, 100% BL and 95.8% LL, while 5% of ENL samples were positive for S-100 antigen. Mean S-100 levels in these different categories of patients were significantly higher Ind--0.45 ng/ml, TT--0.32 ng/ml, BT--0.23 ng/ml, BL--0.23 ng/ml, LL--0.19 ng/ml as compared to that of normal 0.07 ng/ml. In general S-100 seems to be a more sensitive and reliable marker than anticeramide antibodies for nerve damage. Five out of 7 indeterminate cases show increased levels of S-100, showing an extent of nerve damage similar to that of TT and could be a useful marker for assessing nerve damage in indeterminate patients for better management.

Frequency of cardiorenal syndrome type-I in hospitalized children with acute heart failure in a tertiary-care hospital

OBJECTIVE

To determine the frequency of cardiorenal syndrome in hospitalized children with acute heart failure.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Paediatric Intensive Care Unit, The Aga Khan University Hospital, Karachi, from December 2010 to December 2011.

METHODOLOGY

Sixty eight (68) children with acute heart failure fulfilling the selection criteria were evaluated for worsening of renal function (WRF). Serum creatinine was done at baseline and repeated at 72 hours to see the worsening of renal function. Estimated serum creatinine clearance was calculated by Schwartz formula.

RESULTS

Mean age of patients was 43.6 ± 55.2 months. There were 43 (63%) males, 70% were under 57 months of age. Mean weight on admission was 14.7 ± 19.13 kg and mean height was 83 cm (± 31.08 SD). Mean serum creatinine on admission was 0.77 mg/dl (± 1.18 SD). Worsening renal function was noted in 55 (81%) of children, out of those, majority 36 (70.5%) were under 5 years of age.

CONCLUSION

Worsening renal function was found in 81% of children admitted with the diagnosis of acute heart failure. Majority (70.5%) were under 5 years of age indicating a closer observation of renal status in younger age group to reduce, morbidity and mortality.

Hepatoprotective activity of methanolic extract of Hiptage bengalensis leaves against CCl₄-induced hepatotoxicity in rats

The objective of the present study was to evaluate hepatoprotective activity of methanolic extract of Hiptage bengalensis (L.) kurz (MEHB) in rats. Hepatic damage was induced by administration of carbontetrachloride(1 ml/kg, b.w, p.o.) in combination with liquid paraffin (1:1) as a single dose on 7th day. The extent of liver damage was studied by estimating biochemical parameters. Administration of MEHB (200 mg & 400 mg/kg) for 6 days before carbontetrachloride administration showed a significant reduction (p < 0.01) of serum liver damage enzymes markers-aspartate transaminase, alanine transaminase, total bilirubin and alkaline phosphatase (ALP). Histopathological changes of hepatic tissue were also evaluated in control and MEHB treated groups. Results also indicated that MEHB possessed potential antioxidant effect by increasing the levels of glutathione and also possessed free radical scavenging activities. The hepatoprotective effect of Hiptage bengalensis (L.) kurz was comparable to standard drug silymarin (50 mg/kg).