Dengue and scrub typhus co-infection in children: Experience of a teaching hospital in an endemic area.

Background: Dengue fever and scrub typhus are considered an endemic disease in the Indian subcontinent. The epidemiology and clinical presentations are complex and vary each year. Objective: The objective of this study was to estimate the prevalence of coinfection with scrub typhus in children diagnosed with dengue fever. Methods: A retrospective hospital-based, cross-sectional study was done in the Department of Pediatrics of a teaching hospital in Puducherry. All children (0-14 years) who had enzyme-linked immunosorbent assay (ELISA) reported scrub typhus among those diagnosed with dengue fever (NS1Ag or immunoglobulin M ELISA positivity) during 2012-2016. Medical records with incomplete data were excluded from the study. Odds ratio was calculated to find out the association of coinfections. An independent t-test was used to find out the statistical significance. P < 0.05 was considered statistically significant. Results: Atypical features of dengue were present in 250/318 (78.6%) children. Coinfections were seen in 62/318 (19.4%) children. Scrub typhus was the most common (n = 51/62, 82.2%). The chance of scrub typhus in a dengue serology-positive child is significant when the symptoms are atypical or protracted (OR- 2.6, P = 0.033). Conclusion: High index of suspicion should be present in endemic dengue and scrub typhus coinfection.

Challenges of Universal Newborn Hearing Screening in a Developing Country-a Double-Edged Sword.

Objective to implement Universal Neonatal Hearing Screening (UNHS) in a tertiary academic hospital and identify associated risk factors. Prospective study. Screening tests with Otoacoustic Emissions (OAE) were done among newborns, prior to hospital discharge. In babies who fail OAE twice, Brain Response Audiometry (BERA) was done, failing which they were referred to higher ENT center for repeat testing and hearing rehabilitation. A total 2323 babies were admitted in the neonatal unit during the study period. Only 773 babies (a third) could be screened for the first OAE, two thirds being lost to study right at inception!! Among the 773 neonates, in the "at risk" group of 301 neonates, 31(10%) and in the "not at risk" group of 472 neonates, 30 (6%) were lost to follow up respectively. The occurrence of hearing loss in this study population was 1.3 per 1000. Risk factors were noted in 38.9% of this subgroup with occurrence of hearing loss in "at risk" group being 3.32 per 1000. The implementation of UNHS in a developing country like India, has multiple challenges including infrastructural and non-compliance to follow up. In the meantime, the possibility of compromising 'at-risk" neonates, who are significantly more prone to hearing loss, both neonatal and delayed onset, is an additional grave reality which needs deep considerationin this Herculean task of attaining "universality".

Manual fetal stimulation during intrapartum fetal surveillance: a randomized controlled trial.

BACKGROUND: Manual fetal stimulation, either by mechanical manipulation or by stimulation of the fetal scalp, is known to evoke a fetal heart response in a normal fetus. OBJECTIVE: This study aimed to assess the clinical effectiveness of manual fetal stimulation in the assessment of fetal well-being during labor vs no stimulation among women with a singleton pregnancy and to investigate the maternal and neonatal outcomes in the 2 groups. STUDY DESIGN: This was a randomized controlled trial conducted in the department of obstetrics and gynecology at a tertiary care teaching hospital between 2014 and 2016. The inclusion criteria included women with a singleton pregnancy at ≥37 weeks of gestation with cephalic presentation in labor having one of the following abnormalities on fetal heart tracing: fetal heart rate of <110 bpm or >160 bpm, variable decelerations, late decelerations, and minimal or absent beat-to-beat variability. The exclusion criteria included women requiring immediate cesarean delivery, conditions that would preclude a vaginal delivery, and intrauterine fetal demise or a major fetal congenital abnormality. The women were followed up in labor and randomized to either the manual stimulation group or the no stimulation group when one of the cardiotocography abnormalities were present. In the manual stimulation group, the fetus was stimulated abdominally by holding the head in the palm of 1 hand when the cervical dilatation was <3 cm or vaginally by pinching the scalp of the fetus when the cervical dilatation was ≥3 cm. After delivery, a cord blood sample was collected and pH estimated. Mother and baby were followed up until discharge, and mode of delivery, cord blood pH at birth, Apgar scores at 1 minute and 5 minutes, neonatal intensive care unit admissions, and duration of stay were the outcomes studied. Data were entered and compiled as frequency and percentage for categorical variables. For continuous variables, data were calculated using mean and standard deviation. The chi-square test was used for assessing the association between the intervention and fetal and maternal outcomes. RESULTS: A total of 327 women were included in the trial, of whom 164 were in the manual fetal stimulation group (group 1) and 163 were in the "no stimulation" group (group 2). The cesarean delivery rates were 25.61% in group 1 and 30.67% in group 2 (P=.308). The mean cord blood pH levels at birth were 7.267±0.027 in group 1 and 7.265±0.024 in group 2 (P=.479), and the Apgar scores at 1 minute and 5 minutes (P=.169 and P=.423, respectively, between the 2 groups) were not found to be statistically different among the 2 groups. CONCLUSION: There was no considerable change in fetomaternal outcomes with manual fetal stimulation in women having nonreassuring cardiotocographic changes in labor.

Relationship of Maternal and Neonatal Variables With Breastmilk Sodium.

OBJECTIVE: To determine breastmilk sodium changes in the first 72 hours after birth and to correlate maternal and neonatal variables with maternal breastmilk sodium. METHODS: We enrolled 245 mothers and their exclusively breast-fed neonates in this prospective cohort study. Singleton, inborn babies of greater than 34 weeks gestation, who were exclusively breastfed for the first 72 hours were included. Babies who required neonatal intensive care unit (NICU) admission, top up feeds or discharged before 72 hours were excluded. Study outcomes were changes in breast milk sodium in the first 72 hours and association of high maternal breast milk sodium with various maternal and neonatal variables. RESULTS: Mean (SD) breastmilk sodium steadily declined over the first 72 hours [53.5 (19.2), 38.5 (19.0) and 22.2 (10.6) mmol/L at 24, 48, 72 hours, respectively]. Breastfeeding £8 times per 24 hours in the first three days was the only factor significantly associated with high breastmilk sodium (P=0.008). Maternal age, gravida, mode of delivery, significant neonatal weight loss, hypernatremia, neonatal morbidities like fever, irritability, lethargy and poor suck had no significant correlation with high breastmilk sodium. CONCLUSIONS: Breastmilk sodium shows a steady decline in the first 72 hours after delivery. Feeding ≤8 times per day is associated high breastmilk sodium at 72 hours of age.

Effective clearance of uremic toxins using functionalised silicon Nanoporous membranes.

In-house fabricated silicon nanoporous membranes (SNMs), functionalized for efficient clearance of uremic toxins, can lead to compact and portable dialysis systems. Efficacy of 15 nm thick SNMs, with average pore diameter of 8 nm, was tested for dialysis of two uremic toxins - urea and creatinine using custom made teflon apparatus of 2, 10 and 30 ml. The apparatus consisted of two reservoirs, with the cis containing the uremic fluid, and the trans containing the dialysate. Peristalsis was found to enhance the clearance rate by a factor of four as compared to unstirred condition. Functionalisation of the SNMs reduced protein binding, and surface binding of urea from 23% to negligible values. A lateral array of nine SNMs and a new design for the dialysis apparatus, increased the clearance rate by a factor of twelve from that of the single SNM. The arrays cleared about 42% of urea and 48% of creatinine from 30 ml of diluted serum samples, in 15 min. Periodic replacement of the trans fluid cleared about 81% of high concentration uremic toxins from the cis reservoir in 45 mins. The SNM arrays are stable, reproducible, and with the superior clearance rates for urea and creatinine, they have the potential to be used as membranes for portable hemodialysers.

Waitlisted Transplant Candidates' Attitudes and Concerns Toward Transplantation During COVID-19.

BACKGROUND In solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients, coronavirus disease 2019 (COVID-19) can contribute to a severe clinical course and an increased risk of death. Thus, patients awaiting a SOT or HSCT face the dilemma of choosing between a life-saving treatment that presents a significant threat of COVID-19 and the risk of waitlist dropout, progression of disease, or mortality. The lack of established literature on COVID-19 complicates the issue as patients, particularly those with inadequate health literacy, may not have the resources needed to navigate these decisions. MATERIAL AND METHODS We conducted a standardized phone survey of patients awaiting SOT or HSCT to assess the prevalence of inadequate health literacy and attitudes toward transplant during the COVID-19 pandemic. RESULTS Seventy-one patients completed the survey, with a response rate of 84.5%. Regardless of health literacy, most waitlisted candidates recognized that the current pandemic is a serious situation affecting their care and that COVID-19 poses a significant risk to their health. Despite the increased risks, most patients reported they would choose immediate transplantation if there was no foreseeable end to the pandemic, and especially if the medical urgency did not permit further delay. There were no differences in responses across the patient waitlist groups for heart, kidney, liver, and stem cell transplant. CONCLUSIONS These findings can help transplant centers decide how transplantation services should proceed during this pandemic and can be used to educate patients and guide discussions about informed consent for transplant during the COVID-19 pandemic.

Zinc Status and Febrile Seizures: Results from a Cross-sectional Study.

Objective To estimate the serum zinc levels in children under the age of 5 years with febrile seizures and febrile children without seizures Materials and Methods In this cross-sectional study from 2017 to 2018, 40 children with febrile seizures (simple and complex) were taken as cases. Forty age- and sex-matched febrile children without convulsions were recruited as controls. Serum zinc estimates were analyzed using a spectrophotometer (Biolis 50i-Autoanalyzer). Statistical Analysis The demographic variables and serum zinc estimates were analyzed using the Mann-Whitney test. The odds ratio was used to calculate the association of zinc deficiency in febrile seizures; 5% level of significance was considered. Results The mean serum concentrations of zinc in the cases and controls were 83.8 ± 33.1 µg/dL and 116.3 ± 30.3 µg/dL, respectively ( p = 0.002). Hypozincemia defined by "a serum zinc level of less than 63 µg/dL" was found in 12 (30%) cases and 2(5%) controls with an odds ratio of 8:1. Conclusion Children with febrile seizures had significantly reduced concentrations of zinc in the serum.

Performance of Two Different Pulse Oximeters in Neonatal Transition.

OBJECTIVE: To evaluate the performance of two different pulse oximeter technologies by comparing the time taken to achieve reliable oxygen saturation readings during neonatal transition. METHODS: This cross-sectional study was done to compare the performance of two pulse oximeter technologies - Signal Extraction Technology (SET), and Resistor Calibration (RCAL) technology on 150 inborn, term neonates at birth. Probes of both pulse oximeters were connected to the pre-ductal limb and the time taken to obtain a reliable reading was recorded. Sequential saturation values were recorded every minute till ten minutes of life. Statistical analysis was done with Mann-Whitney U test and intraclass correlation coefficient was calculated. RESULTS: Pulse oximeter with SET recorded reliable readings faster than RCAL technology - Median (IQR) 32 (21-60)s vs. 45 (21.75-105)s, p = 0.021. There was a significant difference in the time to record first saturation readings of the two pulse oximeters when used in normal deliveries [RCAL vs. SET-Median (IQR) 50s (25-120.75) vs. 32.5s (21.75-58.25), p = 0.004] but no such difference was observed in Lower Segment Cesarean section (LSCS) [RCAL vs. SET Median (IQR) 35.5s (18.25-70.75) vs. 31s (20-69.75), p = 0.968]. Sequential saturation readings for every minute for the first 10 min of life were higher with SET vs. RCAL technology. The intraclass correlation coefficient between both pulse oximeters, for each minute, was poor (r < 0.80). CONCLUSIONS: The SET pulse oximeter picked up first saturation values faster than the RCAL technology pulse oximeters. Studies are needed to evaluate effect of this on decisions made during neonatal resuscitation.

Perinatal chikungunya in twins.

We report a case of vertically transmitted chikungunya infection in heterozygous twin neonates presenting as seizures, encephalopathy, midfacial hyperpigmentation, anemia, and thrombocytopenia. This could be considered as a rare cause of neonatal seizure and identification would help in appropriate management.

Bilateral torsion of testes with purpura fulminans.

BACKGROUND: Purpura fulminans and bilateral perinatal testicular torsion are rare and may co-exist. CASE CHARACTERISTICS: A 3-day-old neonate with bilateral swelling of scrotum; torsion and gangrenous changes were observed on exploration. INTERVENTIONS: Left orchidectomy with preservation of right testis was done. OUTCOME: At 2-month follow-up, right testis showed signs of atrophy. Child developed full thickness skin lesions and died of sepsis. MESSAGE: Perinatal testicular torsion can be bilateral, and requires urgent surgical exploration.

Early versus Late Parenteral Nutrition in Very Low Birthweight Neonates: A retrospective study from Oman.

OBJECTIVES: The aim of this study was to compare the biochemical parameters, weight gain, osteopenia and phosphate supplementation in very low birth weight (VLBW) neonates receiving early versus late parenteral nutrition (EPN versus LPN). METHODS: A RETROSPECTIVE STUDY WAS UNDERTAKEN IN THE LEVEL III NEONATAL INTENSIVE CARE UNIT AT SULTAN QABOOS UNIVERSITY HOSPITAL, OMAN: from January 2007 to October 2008 (LPN group, n = 47) and from January 2009 to June 2010 (EPN group, n = 44). Demographic data, anthropometric and laboratory parameters were extracted from the electronic record system. RESULTS: The mean age of PN initiation was LPN = 47.3 hours versus EPN = 14.3 hours. Biochemical parameters analysed during the first week of life revealed a reduction in hypernatraemia (12.7% versus 6.8%) and non-oliguric hyperkalemia (12.7% versus 6.8%) in EPN, with no significant differences in acidosis and urea levels between the two groups. Hyperglycemia >12 mmol/L in <1000g was higher in EPN. Nutritional parameters in 81 babies who survived/stayed in the unit up to a corrected gestational age (CGA) of 34 weeks (40 in LPN and 41 in EPN), revealed a reduction in metabolic bone disease (osteopenia of prematurity [OOP], 17.5% versus 7.3%) and the need for phosphate supplementation (22.5% versus 7.3%) in the EPN group. There was no increase in acidosis or cholestasis. No difference was noted in albumin levels, time to full feeds, time to regain birthweight and mean weight gain per day till 34 weeks corrected CGA. CONCLUSION: EPN in VLBW newborns is well tolerated and reduces hypernatraemia, non-oliguric hyperkalemia, OOP and the need for phosphate supplementation.

Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone.

OBJECTIVE: Prone sleeping is a major risk factor for the sudden infant death syndrome and is associated with lower blood pressure and impaired arousability from sleep, both of which may be signs of cerebral hypoxia. However, the impact of sleep position on cerebral oxygenation during infancy remains unknown. We assessed the effects of sleeping position, sleep state, and postnatal age on cerebral oxygenation by measuring tissue oxygenation index (TOI) during the first 6 months of infancy. SUBJECTS AND METHODS: Seventeen healthy term infants (8 girls and 9 boys) were recruited as study participants. Infants were studied at ages 2 to 4 weeks, 2 to 3 months, and 5 to 6 months by use of daytime polysomnography, with additional measurements of blood pressure (Finometer, FMS Finometer Medical Systems, Amsterdam, Netherlands) and tissue oxygenation index (TOI) (NIRO 200 spectrophotometer, Hamamatsu Photonics KK, Tokyo, Japan). RESULTS: In infants who slept in the prone position, TOI was lower in both quiet sleep (QS) and active sleep (AS) at age 2 to 4 weeks and in QS at age 2 to 3 months (P < .05). TOI was lower in AS compared with QS in infants aged 2 to 4 weeks (P < .05). When the infants reached 5 to 6 months of age, TOI was greater in AS (P < .05), as there was a profound decrease in TOI during QS (P < .05) over this period. No relationship was identified between blood pressure and TOI at any age. CONCLUSIONS: In healthy infants cerebral oxygenation is reduced during sleep in the prone position. This reduction may underpin the reduced arousability from sleep exhibited by healthy infants who sleep prone, a finding that provides new insight into potential risks of prone sleeping and mechanisms of sudden infant death syndrome.

Necrotizing enterocolitis in a term neonate following intravenous immunoglobulin therapy.

A term baby with severe BO isoimmunization was treated with intravenous immunoglobulin. Shortly after the completion of the infusion, the baby developed clinical and radiological signs of necrotizing enterocolitis, with intestinal perforation and massive hemorrhagic ascites, resulting in the death of the baby.

Assessing the antidepressant-like effects of carbetocin, an oxytocin agonist, using a modification of the forced swimming test.

RATIONALE: The distribution of oxytocin receptors in limbic regions, as well as evidence that exogenous oxytocin modulates affect and fear processing, suggests that this neuropeptide may have a role to play in the treatment of mood disorders. OBJECTIVES: This study compared the effects of acute treatment with the oxytocin receptor agonist, carbetocin with the tricyclic antidepressant, imipramine, using male Sprague-Dawley rats. METHODS: Intracerebroventricular (i.c.v.; 1, 10, 100 microg/rat), intravenous (i.v.; 2.5, 5 mg/kg), and intraperitoneal (i.p.; 2, 6.4, 20 mg/kg) carbetocin and imipramine (1.8, 5.6, 10 mg/kg, i.p.) were examined in the modified forced swim and open field tests. The mechanism of action of carbetocin was investigated by co-administering it with the oxytocin antagonist, atosiban, either centrally (5 microg/rat, i.c.v.) or systemically (1 mg/kg, i.v.). RESULTS: Imipramine and carbetocin (all three routes of administration) both significantly reduced immobility and increased swimming and/or climbing behavior in the forced swim test. The systemic effects of carbetocin were blocked by central and systemic atosiban co-administration. Only amphetamine (2 mg/kg, i.p.), included as a false positive in order to distinguish whether antidepressant-like effects were due to psychomotor stimulation, increased locomotor activity in the open field test. CONCLUSIONS: Carbetocin produced antidepressant-like changes in behavior via activation of oxytocin receptors in the CNS. The similarities between imipramine and carbetocin in the forced swim test suggest that drugs which target the oxytocinergic system may aid both the understanding and pharmacological treatment of depressive illness.

Caudal Regression Syndrome with Partial Agenesis of the Corpus callosum and Partial Lobar Holoprosencephaly: Case report.

Caudal regression syndrome is a rare fetal condition of diabetic pregnancy. Although the exact mechanism is not known, hyperglycaemia during embryogenesis seems to act as a teratogen. Independently, caudal regression syndrome (CRS), agenesis of the corpus callosum (ACC) and partial lobar holoprosencephaly (HPE) have been reported in infants of diabetic mothers. To our knowledge, a combination of all these three conditions has not been reported so far.

Fatty acid oxidation disorder as a cause of sudden infant death syndrome (SIDS)--a case report.

Although the cause of sudden infant death syndrome (SIDS) remains unknown, extensive studies over the last 10 years have begun to shed some light on this family tragedy. 5% of all cases of SIDS are caused by fatty acid oxidation disorders. We report a case of fatty acid oxidation disorder causing SIDS.

The International HapMap Project Web site.

The HapMap Web site at http://www.hapmap.org is the primary portal to genotype data produced as part of the International Haplotype Map Project. In phase I of the project, >1.1 million SNPs were genotyped in 270 individuals from four worldwide populations. The HapMap Web site provides researchers with a number of tools that allow them to analyze the data as well as download data for local analyses. This paper presents step-by-step guides to using those tools, including guides for retrieving genotype and frequency data, picking tag-SNPs for use in association studies, viewing haplotypes graphically, and examining marker-to-marker LD patterns.