Adjuvant therapy in neonatal sepsis to prevent mortality - A systematic review and network meta-analysis.

BACKGROUND: Despite appropriate antibiotic therapy, the risk of mortality in neonatal sepsis still remains high. We conducted a systematic review to comprehensively evaluate different adjuvant therapies in neonatal sepsis in a network meta-analysis. METHODS: We included randomized controlled trials (RCTs) and quasi-RCTs that evaluated adjuvant therapies in neonatal sepsis. Neonates of all gestational and postnatal ages, who were diagnosed with sepsis based on blood culture or sepsis screen were included. We searched MEDLINE, CENTRAL, EMBASE and CINAHL until 12th April 2021 and reference lists. Data extraction and risk of bias assessment were performed in duplicate. A network meta-analysis with bayesian random-effects model was used for data synthesis. Certainty of evidence (CoE) was assessed using GRADE. RESULTS: We included 45 studies involving 6,566 neonates. Moderate CoE showed IVIG [Relative Risk (RR); 95% Credible Interval (CrI): 1.00; (0.67-1.53)] as an adjunctive therapy probably does not reduce all-cause mortality before discharge, compared to standard care. Melatonin [0.12 (0-0.08)] and granulocyte transfusion [0.39 (0.19-0.76)] may reduce mortality before discharge, but CoE is very low. The evidence is also very uncertain regarding other adjunctive therapies to reduce mortality before discharge. Pentoxifylline may decrease the duration of hospital stay [Mean difference; 95% CrI: -7.48 days (-14.50-0.37)], but CoE is very low. CONCLUSION: Given the biological plausibility for possible efficacy of these adjuvant therapies and that the CoE from the available trials is very low to low except for IVIG, we need large adequately powered RCTs to evaluate these therapies in sepsis in neonates.

Correlation of functional echocardiography and clinical parameters in term neonates with shock.

BACKGROUND: To evaluate the correlation between functional echocardiography and clinical parameters in term neonates with shock. METHOD: Cross sectional study of 30 full term newborns who were clinically detected to have shock compared to 30 full term hemodynamically stable neonates. For statistical analysis, cases were further sub classified into cardiogenic and septic shock. RESULT: Functional echocardiography revealed inferior vena cava collapsibility index (cIVC), fractional shortening (FS), ejection fraction (EF), cardiac output and superior vena cava (SVC) flow were significantly lower whereas myocardial performance index (MPI) was significantly higher in babies with cardiogenic and septic shock as compared to the controls. Left ventricular end diastolic area (LVEDA) was significantly higher in cardiogenic shock whereas it was significantly lower in septic shock as compared to the controls. Also, cIVC was significantly lower and LVEDA was significantly higher in cardiogenic as compared to the septic shock. In cardiogenic shock SVC flow correlated significantly with capillary filling time and systolic blood pressure. The correlation between functional echocardiographic parameters of cardiogenic and septic shock showed that EF, FS and MPI were positively and significantly correlated (r 0.742, p 0.022 for EF, r 0.766, p 0.016 for FS and r 0.478, p 0.05 for MPI) whereas SVC flow and cIVC were negatively and significantly correlated between cardiogenic and septic shock (r - 0.655, p 0.045 for SVC flow and - 0.578, p 0.05 for cIVC). CONCLUSION: In the complex environment of neonatal intensive care unit detection of shock continues to be a major challenge. Functional echocardiography provides an adjunct information to the clinical assessment of shock and helps in monitoring the response to treatment.

Retromandibular transparotid approach compared with transmasseteric anterior parotid approach for the management of fractures of the mandibular condylar process: a prospective randomised study.

Fractures of the mandibular condyle lead to displacement of the condyle and loss of the height of the ramus. A retromandibular approach is the most commonly used for open reduction and internal fixation (ORIF) of such fractures. We aimed to compare the complications associated with a retromandibular transparotid approach with a retromandibular transmasseteric anterior parotid (TMAP) approach for their management. Thirty patients were randomly selected into two groups (15 in each): Group A comprised the retromandibular transparotid approach and Group B the retromandibular TMAP. The variables evaluated were: operating time, facial nerve injury, occurrence of Frey syndrome, and sialocoele at one week, four weeks, three months, and six months. The mean (SD) age in group A and B was 33.93 (17.97) years and 33.53 (16.15) years, respectively, and there were 28 men and two women. Mean (SD) exposure time in the transparotid approach was 26.93 (5.19) minutes and 25.4 (8.35) minutes in the TMAP approach. The incidence of facial nerve injury was 2/15 patients in the transparotid group and 3/15 in the TMAP group, all of which resolved within six months. The incidence of sialocoele was 2/15 in the transparotid group. The results did not show any significant difference in complications between the two approaches, but the retromandibular transparotid approach provided straight-line access in fractures of the condylar neck, with fewer incidences of nerve injury. The anterior parotid approach, on the other hand, provided easier access for fractures that were medially dislocated or of the condylar base but had an increased incidence of facial nerve injuries.

Otitis Media with Effusion (OME) in Urban Pediatric Population in a Tertiary Care Centre: A Clinical Study.

Otitis media with effusion (OME) is a common condition affecting children. It is one of the most common causes for reduced hearing in pediatric age group leading to various learning disabilities including delayed speech development. The aim of this study was to find out various epidemiological characteristics and risk factors for developing OME and various treatment modalities depending on the clinical features and their outcomes in urban pediatric population. A prospective comparative study was done in 100 children taken 50 as cases and 50 as controls for a period of 2 years. The risk factors, common presenting features and the examination and investigational findings (tympanometry) of the study condition were compared among the cases and controls. Among the 50 cases, 28 children were treated medically and 22 underwent surgical treatment in the form of Myringotomy and Grommet insertion. The patients were followed up-to 6 months in both groups.

Distribution, antimicrobial resistance and predictors of mortality in neonatal sepsis.

OBJECTIVE: The aim of this study is to investigate etiological agents, patterns of antimicrobial resistance and predictors of mortality in culture proven neonatal sepsis. METHOD: This is a twenty-four month retrospective cohort study of infants with culture proven sepsis. Demographic data, type of isolates and its sensitivity pattern were recorded. Multidrug resistant gram-negative isolates were defined as resistance to any three of five antibiotic classes: extended-spectrum cephalosporins, carbapenems, aminoglycosides, fluoroquinolones and piperacillin-tazobactam. RESULT: A total of 183 case with culture positive sepsis were identified. Early onset sepsis occurred in 59% of cases. The majority of isolates (56.2%) were gram-positive but the most common individual isolates were klebsiella spp. (31.1%), Staphylococcus aureus (24.5%) and coagulase-negative staphylococci (CONS) (22.9%). The pathogen mix in early-onset did not differ from late-onset sepsis. High rates of multidrug resistance were observed in klebsiella spp. (49.1%), Escherichia coli (50%), citrobacter spp (50%), acinetobacter spp. (28.5%), pseudomonas spp. (100%) isolates. Methicillin resistance prevailed in 16.6% of coagulase-negative staphylococci, 24.4% of Staphylococcus aureus and 62.5% of enterococcus spp. Multivariate analysis revealed invasive ventilation and early onset sepsis to be independently associated with increased risk of mortality in contrast to breast milk feeding which is associated with decreased risk of mortality. CONCLUSION: A high degree of antimicrobial resistance underscores the need to understand the pathogenesis of resistance, curtail the irrational prescription of antibiotics in neonates and the requirement for measures to prevent it in low-income and middle-income countries.

Optimization of beam dump shielding for K-130 cyclotron at VECC.

A compact and efficient beam dump shield has been designed using Monte Carlo simulation code FLUKA to facilitate low background measurement of neutron and gamma rays using K130 cyclotron at Variable Energy Cyclotron Centre, Kolkata (VECC). Iron, lead and high density Polyethylene (HDPE) were considered in the design of the beam dump shield. Representative FLUKA simulation results have been validated using in-beam experiment performed on the same beam dump constituents. Experimental neutron and gamma-rays energy spectra have been found to be in fair agreement with the simulation results. Activation of various beam dump shield components were also carried out.

Generation and application of LET calibration curve for neutron dosimetry using CR-39 detector and microwave induced chemical etching.

Microwave induced chemical etching (MICE) has been established as a faster and improved technique compared to other contemporary etching techniques for the development of tracks in a CR-39 detector. However, the methodology could not be applied for LET (linear energy transfer) spectrometry due to lack of a calibration curve using this method. For this purpose, a new LET calibration curve in the range of 12 keV/µm-799 keV/µm was generated considering different ions such as H, Li, C, O, and F on CR-39 having different LETs in water. An empirical relation was established from the obtained calibration curve for determining the value of LET (in water) from the value of V, the ratio of track etch rate to bulk etch rate. For application of this calibration curve in neutron dosimetry, CR-39 detectors were irradiated to neutrons generated from 120 and 142 MeV 16O+27Al systems followed by a similar MICE procedure. The absorbed dose (DLET) and the dose equivalent (HLET) were obtained from the LET spectra and were found to be 13% and 10% higher for 142 MeV 16O+27Al system than those for 120 MeV 16O+27Al system, respectively. The outcome of the study demonstrates the possibility of using the MICE technique for neutron dose estimation by CR-39 via LET spectrometry.

Reconstruction of a Post Traumatic Anterior Maxillary Defect by Transport Distraction Osteogenesis.

Rehabilitation of segmental defects of maxilla presents a reconstructive challenge to obtain an ideal osseous form and height with adequate soft tissue investment. Though variety of prosthetic and surgical reconstructive options like the use of vascularized and non vascularized bone grafts are available they produce less than optimal results. Bone transport distraction is a reliable procedure in various maxillofacial bony defect reconstruction techniques. We describe herein a technique of maxillary bone transport distraction using an indigenously designed, custom made trifocal transport distractor performed in a post traumatic avulsive defect of the anterior maxilla. Transport distraction was successful for anterior maxillary alveolar bony regeneration, with excellent soft tissue cover and vestibular depth, which also helped close an oroantral/oronasal fistula.

Diagnostic Features and Management Strategy of a Refractory Case of Osteoradionecrosis of the Mandible: Case Report and Review of Literature.

INTRODUCTION: Osteoradionecrosis of the jaws produces a considerable amount of esthetic as well as functional deficits seriously affecting quality of life of the patient. Cases are often notoriously difficult to treat and manage owing to associated comorbidities of the patient, post irradiation fibrosis and decreased vascularity at the site, which complicates free tissue flap and graft transfer, that subsequently succumb to failure. Hyperbaric oxygen therapy (HBOT), in which 100 % oxygen is administered by mask under 2.4 atm pressure, in a hyperbaric oxygen chamber, helps by increasing local vascularity. AIM AND METHODS: It was the aim of this study to show that a particularly refractory, compromised and challenging case of osteoradionecrosis can be managed successfully even without HBOT, by mandibular segmental resection followed by reconstruction using a titanium reconstruction plate enveloped within a pedicled Pectoralis Major Myocutaneous flap. RESULT: Post operative recovery of the patient was excellent with good functional and esthetic rehabilitation of the patient with and practically nil donor site morbidity. CONCLUSION: It is important to have a thorough knowledge of the clinical, radiographic, histopathologic, CT and MRI features of osteoradionecrosis of the jaws in order to make a quick and accurate confirmatory diagnosis and to overcome possible diagnostic dilemmas. The strategy of reconstruction of a large mandibular defect using a bridging titanium plate sandwiched by a healthy vascularized myocutaneous flap, following ablative surgery for ORN, has proved to be a safe and reliable option for composite mandibular defects, with gratifying long term functional and cosmetic results.

'Y' Modification of the Transconjunctival Approach for Management of Zygomatic Complex Fractures: A Prospective Analysis.

PURPOSE: The purpose of this study was to clinically and radiologically evaluate reduction and fixation of isolated zygomatic complex (ZMC) fractures treated by Y modification of the transconjunctival approach. PATIENTS AND METHODS: A prospective evaluation of ten patients was undertaken for a period of 6 months using this modified approach from Jan 2012 to Jun 2013. Patients were examined preoperatively and post operatively at the end of 6 months for symmetry discrepancies involving A-P globe projection, lateral canthal level, malar projection and diplopia in direct and extreme gazes. Cosmetic outcomes were assessed by clinical assessment and examination of photographs. Quality of reduction and stability of fixation was assessed by examination of postoperative images. RESULTS: All patients underwent a three point fixation of ZMC with reconstruction of the orbital floor using titanium mesh. Patients were post surgically followed up at regular intervals of 1, 3 and 6 months. Immediate complications noted were chemosis, lid edema and lower lid retraction. Late complications included minor scleral show in two cases. All patients experienced significant improvement with excellent esthetic appearance and function. CONCLUSIONS: Y modification of transconjunctival approach provides excellent surgical exposure for ZMC fractures potentially avoiding the use of a second incision in the area of ZF suture. Although this technique provides good exposure and excellent esthetics, it requires more operating time and detailed knowledge of the anatomy of the lateral canthal region.

Effects of high neutron doses and duration of the chemical etching on the optical properties of CR-39.

Effects of the duration of chemical etching on the transmittance, absorbance and optical band gap width of the CR-39 (Polyallyl diglycol carbonate) detectors irradiated to high neutron doses (12.7, 22.1, 36.0 and 43.5 Sv) were studied. The neutrons were produced by bombardment of a thick Be target with 12 MeV protons of different fluences. The unirradiated and neutron-irradiated CR-39 detectors were subjected to a stepwise chemical etching at 1h intervals. After each step, the transmission spectra of the detectors were recorded in the range from 200 to 900 nm, and the absorbances and optical band gap widths were determined. The effect of the etching on the light transmittance of unirradiated detectors was insignificant, whereas it was very significant in the case of the irradiated detectors. The dependence of the optical absorbance on the neutron dose is linear at short etching periods, but exponential at longer ones. The optical band gap narrows with increasing etching time. It is more significant for the irradiated dosimeters than for the unirradiated ones. The rate of the narrowing of the optical band gap with increasing neutron dose increases with increasing duration of the etching.

Mantle cell lymphoma of the oral cavity with multiple foci: a case report and review of the literature.

Non-Hodgkin lymphomas (NHLs) are often present outside the lymph nodes. Although primary extranodal NHLs form a substantial part of all NHLs, reports on oral primary extra nodal NHLs are rare. Mantle cell lymphoma (MCL) is a rare B-cell neoplasm that has only recently been defined as a distinct entity. MCL of the oral cavity is an uncommon diagnosis. Most oral MCLs occur in an elderly male population and have a possible predilection for the palate. The microscopic diagnosis can be challenging, given its similar appearance to other small cell lymphomas, requiring a comprehensive immunohistochemical panel for the accurate diagnosis. Like MCL occurring in other sites in the body, the prognosis and outcome of oral MCL appears to be poor.

Value of immunohistochemistry in diagnosing a rare case of maxillofacial plasma cell granuloma masquerading as a gingival epulis.

BACKGROUND: Plasma cell granuloma is a non-neoplastic lesion rather uncommonly seen in the maxillofacial region. Its etiology, biological behavior, ideal treatment and prognosis are still unclear and rather controversial. STUDY: A detailed histopathological examination and immunohistochemical study of the excised specimen was carried out, both for making a confirmatory diagnosis as well as to determine the etiopathology, biological behavior and prognosis of the lesion. RESULTS: Light microscopy revealed a hyperplastic stratified squamous epithelial lining, overlying a densely fibrocellular granulation tissue containing a rich proliferation of mononuclear inflammatory cells, among which there was a predominance of plasma cells with their typical eccentric, cartwheel shaped, "clock-faced" nuclei. Strong immunohistochemical positivity was observed for CD-138 by numerous cells of the connective tissue of the lesion, thus confirming them to indeed be plasma cells. Further, immunohistochemistry (IH) analysis also demonstrated the expression of both, the lambda and kappa light chain immunoglobulins by the plasma cell population, thus confirming them to be polyclonal and of an inflammatory, non-neoplastic origin. SUMMARY AND CONCLUSION: As a plasma cell granuloma is rarely encountered in the oral and maxillofacial region, its diagnosis could have been very easily missed, had it not been for the detection of the large numbers of plasma cells by light microscopy, which was further confirmed by IH. IH also helped in establishing the likely etiopathology of the lesion and confirmed it to be of a non-neoplastic reactive/inflammatory origin.

Bed bug outbreak in a neonatal unit.

There has been a worldwide increase in bed bug infestations over the last 10-15 years. A major stigma is placed upon the institutions found to be infested. We report our experience with an outbreak of the tropical bed bug, Cimex hemipterus, in a neonatal unit. The outbreak not only affected the admitted newborns and mothers by causing a wide variety of rashes and inducing sleeplessness, but also impinged upon the health professionals and their families by producing similar symptomology. It is important for healthcare providers to be aware of, and for each healthcare facility to have, bed bug prevention and control policies.

Selection of neutron-absorbing materials to improve the low-energy response of a Zr-based extended neutron monitor using Monte Carlo simulations.

Monte Carlo simulations have been carried out using the FLUKA code to improve the neutron ambient dose equivalent [H*(10)] response of the ZReC (zirconium-lined portable neutron counter responding satisfactorily to neutrons up to 1 GeV) by introducing various neutron absorbers in the system such as cadmium, gadolinium, natural boron, enriched (10)B and borated polythene. It was found that ZReC can be effectively used as a portable neutron monitor by introducing any one of the following perforated layers: 5 mm thick natural boron, 0.5 mm thick enriched (10)B or 1 cm high-density polythene mixed with 50 % boron by weight. The integral response of the instrument was also calculated for some typical reference neutron fields. The relative ambient dose equivalent response of the said system is also found comparable with that of the existing LINUS neutron monitor.

Neutron dose estimation via LET spectrometry using CR-39 detector for the reaction (9)Be (p, n).

CR-39 detectors, widely used for neutron dosimetry in accelerator radiation environment, have also been applied in tissue microdosimetry by generating the linear energy transfer (LET) spectrum. In this work, the neutron dose has been estimated via LET spectrometry for (9)Be (p, n) reaction which is useful for personnel monitoring around particle accelerators and accelerator based therapy facilities. Neutrons were generated by the interaction of protons of 6 different energies from 4-24 MeV with a thick Be target. The LET spectra were obtained from the major and minor radii of each track and the thickness of removed surface. From the LET spectra, the absorbed dose (D LET) and the dose equivalent (H LET) were estimated using Q-L relationship as given by International Commission on Radiological Protection (ICRP) 60. The track density in CR-39 detector and hence the neutron yield was found to be increasing with the increase in projectile (proton) energy. Similar observations were also obtained for absorbed dose (D LET) and dose equivalents (H LET).

Effects of neutron irradiation on optical and chemical properties of CR-39: Potential application in neutron dosimetry.

Effects of high-dose neutron irradiation on chemical and optical properties of CR-39 were studied using FTIR (Fourier Transform Infrared) and UV-vis (Ultraviolet-Visible) spectroscopy. The primary goal was to find a correlation between the neutron dose and the corresponding changes in the optical and chemical properties of CR-39 resulted from the neutron irradiation. The neutrons were produced by bombarding a thick Be target with 22-MeV protons. In the FTIR spectra, prominent absorbance peaks were observed at 1735cm(-1) (C=O stretching), 1230cm(-1)(C-O-C stretching), and 783cm(-1)(=C-H bending), the intensities of which decreased with increasing neutron dose. The optical absorbance in the visible range increased linearly with the neutron dose. Empirical relations were established to estimate neutron doses from these optical properties. This technique is particularly useful in measuring high doses, where track analysis with an optical microscope is difficult because of track overlapping.

Measurement of neutron spectra generated from bombardment of 4 to 24 MeV protons on a thick 9Be target and estimation of neutron yields.

A systematic study on the measurement of neutron spectra emitted from the interaction of protons of various energies with a thick beryllium target has been carried out. The measurements were carried out in the forward direction (at 0° with respect to the direction of protons) using CR-39 detectors. The doses were estimated using the in-house image analyzing program autoTRAK_n, which works on the principle of luminosity variation in and around the track boundaries. A total of six different proton energies starting from 4 MeV to 24 MeV with an energy gap of 4 MeV were chosen for the study of the neutron yields and the estimation of doses. Nearly, 92% of the recoil tracks developed after chemical etching were circular in nature, but the size distributions of the recoil tracks were not found to be linearly dependent on the projectile energy. The neutron yield and dose values were found to be increasing linearly with increasing projectile energies. The response of CR-39 detector was also investigated at different beam currents at two different proton energies. A linear increase of neutron yield with beam current was observed.