Do babies with isolated single umbilical artery need routine postnatal renal ultrasonography?

BACKGROUND: The presence of isolated single umbilical artery (SUA) in infants has been associated with an increased risk of occult renal malformations. However, the need for routine postnatal renal imaging of such infants, especially in an era of now routine antenatal fetal sonography, is controversial. AIM: To determine the prevalence of significant renal anomalies and the need for routine postnatal renal imaging in infants with isolated SUA. METHODS: Consecutive infants born over 6 years with isolated SUA were offered renal sonography at 4-8 weeks of age. The prevalence of clinically significant renal anomalies in these infants was compared with that detected through routine antenatal fetal scanning and postnatal case findings in a geographically defined control cohort. RESULTS: During the study period, SUA was found in 137 of 33 067 (4.1/1000) live born infants. Infants with isolated SUA (n = 129) were significantly more likely to be preterm and small for gestational age. 122 infants with isolated SUA (95%) underwent renal ultrasonography; only two infants (1.6%, 95% CI 0.20 to 5.5) had clinically significant renal anomalies, a prevalence similar to that in the control cohort (0.4%, 95% CI 0.29 to 0.45; p = 0.74). Four of eight infants with coexistent systemic malformations had abnormal postnatal renal imaging. CONCLUSION: The presence of isolated SUA is associated with increased risk of prematurity and fetal growth restriction. In this largest series of isolated SUA, there was no excess of significant renal malformations among infants with isolated SUA. Postnatal renal ultrasonography is not routinely warranted in such infants.

Enteric fever in Mumbai--clinical profile, sensitivity patterns and response to antimicrobials.

AIMS: Enteric fever is endemic in Mumbai and its diagnosis poses several problems. Our main aim was to study the clinical profile, haematological features of culture proven typhoid cases, the antimicrobial susceptibility pattern of the isolates and the time to defervescence with the treatment received. MATERIAL AND METHODS: This was a retospective chart review of all cases of culture proven enteric fever carried out at a tertiary care private hospital in Mumbai over the period January 2003 to September 2005. RESULTS: Culture positivity in our study was 52.6%. Sixty one percent of the isolates were Salmonella typhi while 39% were Salmonella paratyphi A. An absolute eosinopenia was seen in 76.9% of the patients. Before being admitted to the hospital, 46.2% received antibiotics. The mean time to defervescence in patients who received prior antibiotics was 4.5 days while that in those who did not receive prior antibiotics was 5.1 days. CONCLUSIONS: A high culture positivity despite prior or ongoing antibiotic treatment was seen. Absolute eosinophil count of 0% could be an important marker of typhoid. High prevalence of nalidixic acid resistance, a marker of resistance to fluoroquinolones was observed. Combination treatment was not found to be superior to treatment with a single antibiotic.

Impact of preoperative screening for meticillin-resistant Staphylococcus aureus by real-time polymerase chain reaction in patients undergoing cardiac surgery.

We report a significant reduction in the number of surgical site infections (SSIs) due to meticillin-resistant Staphylococcus aureus (MRSA) in patients undergoing cardiac surgery after the introduction of preoperative screening using a same-day polymerase chain reaction (PCR) test. This was an observational cohort study set in a cardiac surgery unit based in southwest England. We studied 1462 patients admitted for cardiac surgery between October 2004 and September 2006. The IDI MRSA PCR test was used preoperatively to screen 765 patients between October 2005 and September 2006. Patients identified as carriers were treated with nasal mupirocin ointment and topical triclosan for five days, with single-dose teicoplanin instead of flucloxacillin as perioperative antibiotic prophylaxis. The rate of SSI following cardiac surgery in this group was compared to 697 patients who underwent surgery without screening between October 2004 and September 2005. After introduction of PCR screening, the overall rate of SSI fell from 3.30% to 2.22% with a significant reduction in the rate of MRSA infections (relative risk reduction: 0.77; 95% confidence interval: 0.056-0.95). PCR screening combined with suppression of MRSA at the time of cardiac surgery is feasible in routine clinical practice and is associated with a significant reduction in subsequent MRSA SSIs.

Management of Combat Related Vascular Injuries in a Zonal Hospital.

BACKGROUND: The extremity gunshot wound (GSW) and penetrating splinter injuries from mine blast present a surgical challenge in the treatment of arterial trauma especially at non-vascular surgery centre. Adherence to specific principles of management is required for optimal limb salvage. METHODS: Fourteen vascular injuries in patients of GSW and mine explosions were managed at a zonal military hospital with successful outcome in two years. The diagnosis of arterial injury was done clinically. RESULTS: The commonest site of vascular injury was femoral. The methods of choice for repair were autogenous vein interposition or end-to-end anastomosis. All except for two patients retained a functional limb. CONCLUSION: All surgeons in peripheral hospitals should be trained in vascular injury repair to save life and limb. Our series shows that right timing and prompt treatment of vascular injuries in a peripheral hospital, can give satisfactory results.

Mine Blast Injuries - Our Experience.

BACKGROUND: The sudden increase in incidence and magnitude of mine blast injuries prompted us to highlight the problem and its management. METHODS: The cases of mine blast injuries occurring during mining and demining in a particular geographical area were analysed. Total 27 cases of mine blast injuries occurred during mining or demining operations in a period of 13 months. RESULTS: Various body regions were involved in the mine blast injuries but the main brunt was borne by feet and legs followed by multiple body regions due to splinters. 14 patients underwent below knee (BK) amputation while 4 patients required through knee (TK) amputations. The effect of blast was so severe that most of the cases required 2 to 5 times wound debridements. The initial aggressive debridement / open stump amputation saved the limb and life of all patients. CONCLUSION: A mine blast causes extensive injuries and psychological trauma. Management is needed urgently, surgery is difficult, and amputation is often inevitable. Maximum lives and limbs can be saved with aggressive debridement, repeated inspections and dressings under anaesthesia and definitive closure at optimum time.

Terrorism, Trauma and Children.

BACKGROUND: Terrorist attacks, armed conflict and all forms of catastrophe, tax our ability to cope, understand and respond to the situation. Children are more vulnerable. MATERIAL & METHOD: 16 children, victims of a terrorist attack in an army residential camp were managed for their physical injuries and evaluated for psychological trauma. RESULTS: All patients recovered from physical injuries, except one baby of two months, who died due to severe chest trauma. 5 children presented with Acute Stress Reaction. 3 recovered well and two, showed persistent poor scholastic performance even after one year. CONCLUSION: A terrorist attack, not only results in physiscal scars but also causes psychological trauma, which requires emotional support and needs to be followed up on a long term basis.

Use of a new medium - tobacco agar, for pigment production of Cryptococcus neoformans.

Cryptococcus neoformans produces brown colonies on Niger seed (Guizotia abyssinica) agar. Media containing caffeic acid, L-dopa and other diphenolic compounds, have been used for the same purpose. The present report describes a new medium containing tobacco which supports growth of C.neoformans and allows its easy differentiation by formation of brown coloured colonies.

Appendicitis During Pregnancy.

Acute appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy [1]. Six young female patients presented with appendicitis during May 1996 to May 2001 in different service hospitals. Five patients underwent emergency appendectomy successfully. Gestational age at presentation included first trimester in 4 patients, second trimester in 2 patients and none in third trimester. 84% had pathologically proven acute appendicitis. One patient presented with appendicular lump in first trimester, proved on ultra sonography examination, which was treated by Oshner Sherren regime and subsequently interval appendectomy was done in second trimester. No long term adverse maternal morbidity or mortality was reported. One patient had premature onset of labour and delivered. Natural history of acute appendicitis is not changed during pregnancy while gestational physiological changes obscure the accurate diagnosis of acute appendicitis.

Perinatal immunomodulation.

The fetus and the neonate are particularly vulnerable to injury caused directly by immunologic mechanisms or inflicted by infectious agents that take advantage of their relatively immature and inexperienced immune system. With increasing survival of high-risk neonates in the surfactant era, prevention/treatment of sepsis and chronic lung disease (CLD) has emerged as an area of priority in neonatal research. Considering the role of inflammatory mediators in the pathogenesis of sepsis and CLD, the clinical application of immunomodulator therapy to neonatology is perhaps more important at present than ever. Advances in molecular biology and immunology have led to development of newer immune modulator therapies that are directed towards specific cells or cytokines rather than resulting in a general suppression of the immune response. Failure of promising, newer immunomodulator therapies in sepsis trials in adults has, however, clearly documented the difficulties in diagnosing/correcting the imbalance between pro- and anti-inflammatory responses. As in the case of sepsis, development of a single magic bullet for prevention/management of a multi-factorial illness like CLD may be difficult, as prevention of prematurity - the single most important high-risk factor for CLD - is an unachievable goal at present. As new frontiers are being explored, older, well-established therapies like antenatal anti-D immunoglobulin prophylaxis continue to emphasize the tremendous potential of immunomodulator therapy in neonatology/perinatology. The current immunomodulators/immunotherapeutic agents with established/potential clinical applications in the perinatal period are reviewed.

Congenital scoliosis in a neonate: can a neonatologist ignore it?

The frequency of diagnosis of congenital scoliosis in the neonatal period is expected to rise given the increasing survival of high risk neonates in the surfactant era and their frequent exposure to x rays. Considering its significant long term implications a neonatologist cannot afford to ignore the diagnosis of congenital scoliosis in a neonate as close surveillance, early detection, and treatment may prevent/minimise the wide spectrum of potentially serious deformities that can affect the developing spine. The review provides general guidelines to help the neonatologists in counselling the parents and in planning the multidisciplinary follow up for management of congenital scoliosis.

Diaphragmatic paralysis in extremely low birthweight neonates: Is waiting for spontaneous recovery justified?

Mortality and morbidity associated with surgical management of patent ductus arteriosus (PDA) in neonates has been reported to vary from 0% to 44%. Complications like pneumothorax, pleural effusion, recurrent nerve and phrenic nerve injury are associated with surgical closure of PDA. An extremely low birthweight neonate with diaphragmatic paralysis following phrenic nerve injury during surgical closure of PDA is reported. Delay in diaphragmatic plication for over two weeks while waiting for spontaneous recovery was associated with significant morbidity including chronic lung disease. The controversies associated with timing of diaphragmatic plication in high-risk neonates are discussed.

Unusual presentation of neonatal Behcets disease.

Intrauterine growth retardation and neonatal transient mucocutaneous lesions ("transient Behcet syndrome") have been reported in pregnancies complicated by Behcets disease (BD). Neonatal neurological manifestations have not been reported in such pregnancies. Vascular and neurological involvement is known to worsen the prognosis in adults with BD. The clinical course and outcome of a 34-weeks' gestation neonate born to a mother with BD is reported. Progressive recovery from minimal respiratory distress syndrome was followed by catastrophic presentation on 6th day of life with generalized seizures. Cranial ultrasound revealed multiple hyperechoic lesions in the frontal, parietal, and periventricular regions with a few surrounded by a ring of reduced echogenicity suggesting haemorrhage into ischemic areas. Death occurred after withdrawal of life support on Day 9, after extensive discussions with parents in view of the progressive deterioration in the neonates' general condition and the cranial ultrasound findings. Strong family history of BD, clinical course, and laboratory results (no evidence of disseminated intravascular coagulation, normal levels of protein C and S, absence of factor V Leiden and anticardiolipin antibodies) suggested neurological manifestations of BD as the most probable diagnosis.

Infant feeding practices in urban population--a clinic based study.

A clinic based cross-sectional study was conducted at Immunoprophylaxis Clinic at Govt. Medical College, Nagpur. Mothers of 217 children were interviewed for infant feeding practices. In 62.67% of children, breast-feeding was initiated within 24 hrs. after birth. About 22% mother used prelacteal feed and 70% mothers preferred demand feeding. Prominent area of concern includes discarding of colostrum, low exclusive breast feeding rate, delayed weaning and early termination of breast feeding. Further improvement in present day infant feeding practices is possible by emphasising on the health education component of existing nutritional programmes.