Haribalakrishna Balasubramanian

Early probiotics to prevent childhood metabolic syndrome: A systematic review.

AIM To conduct a systematic review of studies on early probiotic supplementation to prevent childhood metabolic syndrome (MS). METHODS Using the Cochrane systematic review strategy we searched PubMed, EMBASE, CENTRAL, CINAHL, and the conference proceedings of the Pediatric American Society meetings and trial registries in December 2014. Randomised controlled trials (RCTs) and non RCTs of probiotic supplementation to the mother and/or infant for a minimum duration of 4 wk were selected. Of these, studies that reported on MS or its components (obesity, raised blood pressure, hyperglycemia, dyslipidemia) in children between 2-19 years were to be eligible for inclusion in the review. Risk of bias (ROB) in selected RCTs and quality assessment of non-RCT studies were to be assessed by the Cochrane ROB assessment table and New Castle Ottawa scale. RESULTS There were no studies on early probiotic administration for prevention of childhood MS (CMS). Follow up studies of two placebo controlled RCTs (n = 233) reported on the effects of early probiotics on one or more components of MS in children aged 2-19 years. Meta-analysis of those two studies could not be performed due to differences in the patient population, type of outcomes studied and the timing of their assessment. Assessment of childhood metabolic outcomes was not the primary objective of these studies. The first study that assessed the effects of prenatal and postnatal supplementation of Lactobacillus rhamnosus GG on body mass index till 10 years, did not report a significant benefit. In the second study, Lactobacillus paracasei 19 was supplemented to healthy term infants from 4-13 mo. No significant effect on body mass index, body composition or metabolic markers was detected. CONCLUSION Current evidence on early probiotic administration to prevent CMS is inadequate. Gaps in knowledge need to be addressed before large RCTs can be planned.

Effect of two different doses of parenteral amino acid supplementation on postnatal growth of very low birth weight neonates — A randomized controlled trial

ObjectivesTo evaluate the effects of two different doses of parenteral aminoacid supplementation on postnatal growth in Very Low Birth Weight (VLBW) infants receiving partial parenteral nutrition (PPN).DesignDouble blinded randomized controlled trial.SettingsLevel 3 NICU between February 2008 to February 2010.Participants150 inborn babies with birthweight between 900–1250 g, irrespective of gestational age, were randomized to either of the two interventions of amino acid supplementation.InterventionTwo different initial doses of parenteral amino acids (AA) in the PPN solutions- Low AA group: 1 g/kg/d versus High AA group: 3 g/kg/d from day 1 of life with increment by 1 g/kg every day till a maximum of 4 g/kg/d, until babies tolerated 75% enteral feeds.Main outcomeAverage postnatal weight gain (in g/kg/d)) by 28 days of life.ResultsBoth groups had similar baseline characteristics. The gain in weight, length and head circumference at 28 days were significantly lower in the High AA group. The average weight gain at 28 days was 8.67g/kg/d in the High AA group and 13.15g/kg/d in the Low AA group (mean difference 123.12, 95% CI 46.67 to 199.37, P<0.001). The incidences of neonatal morbidities associated with prematurity were similar in both groups.ConclusionHigher initial parenteral aminoacid supplementation, in settings where partial parenteral nutrition is administered, results in poor growth in VLBW infants due to inadequate non-protein calorie intake.

Odds ratio vs risk ratio in randomized controlled trials

Abstract Objective. Use of odds ratio (OR) in randomized controlled trials (RCTs) has been criticized because it overestimates the effect size, if incorrectly interpreted as risk ratio (RR). To what extent does this make a difference in the context of clinical research is unclear. We, therefore, aimed to address this issue considering its importance in evidence-based practice of medicine. Methods. We reviewed 580 RCTs published in the New England Journal of Medicine between January 2004 and June 2014 and identified 107 RCTs that reported unadjusted RR (n = 76) or OR (n = 31) for the primary outcome. For studies reporting ORs, we calculated RRs, and vice versa, using Stata software. The percentage of divergence between the reported and calculated effect size estimates was analyzed. Results. None of the RCTs showed a statistically significant result becoming insignificant or vice versa depending on the effect size estimate. OR exaggerated the RR in 62% of the RCTs. The percentage of overestimation was > 50% in 28 RCTs and > 100% in 13 RCTs. The degree of overestimation was positively correlated with the prevalence of outcomes (spearman’s rho = 0.84 and 0.66, p < 0.001). Conclusion. Use of OR instead of RR in RCTs does not change the qualitative inference of results. However, the use of OR can markedly exaggerate the effect size in RCTs if misinterpreted as RR and, hence, has the potential to mislead clinicians.

Effect of gastric lavage on feeding in neonates born through meconium-stained liquor: a systematic review

Objective To evaluate the efficacy and safety of gastric lavage (GL) in neonates born through meconium-stained liquor (MSL). Design A systematic review of randomised controlled trials by searching databases MEDLINE (from 1966), EMBASE (from1980), CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar and proceedings of Pediatric Academic Society meetings (2002–2014). Setting Delivery room/Neonatal ward. Patients Neonates with gestation >34 weeks and birth weight ≥1800 g born through MSL. Interventions Prophylactic GL versus no intervention before first feed. Main outcome measure Feeding intolerance, defined as inability to initiate/upgrade feeds due to problems such as retching, vomiting, regurgitation and gastric residuals. Results A total of six studies (GL: 918, no GL: 966) were included in the review. Meta-analysis using fixed-effects model showed decreased incidence of feed intolerance following GL ((81/918 (8.8%) vs 114/966 (11.8%); risk ratio (RR): 0.71 (95% CI 0.55 to 0.93)). However, the results were not significant when random-effects model was used (RR: 0.78 (95% CI 0.55 to 1.09)). No significant adverse effects of GL were reported. Conclusions Routine GL immediately after birth may improve feed tolerance in neonates born through MSL. However, the evidence is limited, with probable small-study bias and high risk of bias in a number of the included studies. Well-designed studies with adequate sample size are essential to confirm these findings.

Developmental outcomes in cerebrospinal fluid proven enteroviral meningitis in neonates > 32 weeks of gestation

The aim of this study is to assess the short‐term and long‐term (1 year) outcomes of cerebrospinal fluid (CSF) confirmed enteroviral meningitis in neonates > 32 weeks of gestation.

Postoperative Stridor following Repair of Tracheoesophageal Fistula: A Case Report

We report a case of prolonged post-operative stridor in a full-term neonate who was operated for tracheoesophageal fistula. Initial evaluation including an endoscopy and contrast-enhanced computed tomography scan was normal. Repeat endoscopic evaluation under anesthesia revealed tight aryepiglottic folds. Aryepiglottic split was performed and stridor improved dramatically. Tight aryepiglottic folds should be kept in differential diagnosis in a case of postoperative stridor in an infant.

Placental Findings in Singleton Stillbirths: A Case-control Study

Aims This prospective observational study compared placental lesions of stillbirth cases and live birth controls, and aimed to determine the cause of stillbirth. Methods The study enrolled 85 stillbirths and 85 live births at the time of delivery. Results There was significantly increased incidence of placental abruption (p = 0.005) and gestational diabetes (p = 0.032) in mothers with stillbirths. Histopathological examination of placenta was significantly abnormal in stillbirths compared with live births (p = 0.004). Delayed villous maturation was significantly more in stillbirths (38.82 vs. 16.47%; p = 0.002). Acute (30.59 vs. 16.47%; p = 0.04) and chronic diffuse villitis (16.47 vs. 4.7%; p = 0.02), chorionic plate acute vasculitis (28.235 vs. 14.11%; p = 0.04) were significantly more in stillbirths. Foetal vascular thrombi in the chorionic plate (30.58 vs. 14.12%; p = 0.02) and avascular villi (24.7 vs. 8.23%; p = 0.006) were significantly more in stillbirths. Conclusion These abnormal placental patterns could provide information about the etiopathogenisis in stillbirths of unknown aetiology.

Role of massage therapy on reduction of neonatal hyperbilirubinemia in term and preterm neonates: A review of clinical trials

Abstract Background: Neonatal hyperbilirubinemia (NNH) is one of the leading causes of admissions in nursery throughout the world. It affects approximately 2.4–15% of neonates during the first 2 weeks of life. Aims: To evaluate the role of massage therapy for reduction of NNH in both term and preterm neonates. Method: The literature search was done for various randomized control trials (RCTs) by searching the Cochrane Library, PubMed, and EMBASE. Results: This review included total of 10 RCTs (two in preterm neonates and eight in term neonates) that fulfilled inclusion criteria. In most of the trials, Field massage was given. Six out of eight trials reported reduction in bilirubin levels in term neonates. However, only one trial (out of two) reported significant reduction in bilirubin levels in preterm neonates. Both trials in preterm neonates and most of the trials in term neonates (five trials) reported increased stool frequencies. Conclusion: Role of massage therapy in the management of NNH is supported by the current evidence. However, due to limitations of the trials, current evidences are not sufficient to use massage therapy for the management of NNH in routine practice.

Failure of Oral Valganciclovir Treatment in Congenital Cytomegalovirus Hepatitis in a Neonate

A preterm (31 weeks) female neonate born at home was admitted to our tertiary neonatal unit. She was a growth restricted fetus with birth weight 1085 g (<10th centile), length 35 cm (<10th centile), and head circumference 27 cm (<10th centile). She required continuous positive airway pressure for 20 hours and was graded to full feeds by 7 days. Head ultrasounds on days 1 and 7 of life were suggestive of bilateral subependymal hemorrhages and calcifying vasculopathy of the basal ganglia from subclinical hypoxia-ischemia. The postnatal course in the first 7 weeks was uneventful except for poor weight gain and persistent mild thrombocytopenia (platelet count of 100-150 × 10/L). By the end of week 7, she developed conjugated hyperbilirubinemia and deranged liver functions (alkaline phosphatase 1040 U/L, conjugated bilirubin 67 μmol/L, alanine transferase 77 U/L). Onset of hepatitis with a background of fetal symmetrical growth restriction and mild thrombocytopenia, led to cytomegaloviral (CMV) culture being performed on urine. All 3 consecutive daily urine samples were culture positive for CMV. The serum CMV IgM levels were equivocal. The dried blood spot that had been collected at 72 hours of life for newborn screening was retrospectively tested and confirmed to be positive for CMV DNA and hence, a diagnosis of symptomatic congenital CMV was made. After discussing the pros and cons of intravenous versus oral antiviral therapy, oral valganciclovir (VGCV) treatment was commenced in week 8 at a dose of 15 mg/ kg/dose twice daily with a plan to continue for 6 months. Weekly CMV viral loads, liver function tests, and complete blood count were monitored in the initial phase of therapy. At the end of 3 weeks of VGCV therapy, there was no reduction in viral load (Table 1). At this point, blood levels of ganciclovir were undetectable and there was progressive worsening of liver functions. Hence, oral VGCV was ceased and intravenous ganciclovir therapy commenced at the dose of 5 mg/kg twice daily. This resulted in immediate improvement, associated with a substantial reduction in the viral load within a week of commencement (Table 1). Liver functions improved over a period of 4 weeks and improvement in weight gain was noted. There were no adverse effects with ganciclovir therapy. Intravenous ganciclovir was administered for 6 weeks and was followed by oral VGCV. She was discharged at a postterm age of 6 weeks with a plan to continue oral VGCV for 6 months. At discharge, the weight was 3000 g (<3rd centile), length was 50 cm (<3rd centile), and head circumference was 37 cm (41st centile). Neurological examination at the time of discharge was normal.

Handling Complaints, Meetings, and Presentations

Being responsible for handling complaints, meetings, and presentations is a part and parcel of work life, especially as one rises higher up in the workforce hierarchy. Effective complaint management is important in order to deliver high quality services to the satisfaction of the consumers/clients while maintaining the accreditation standards and credentialing criteria, using clinical and performance indicators. Understanding the essentials of complaint management is therefore important for advanced trainees, as well as supervisors and managers in any workplace. Health care organisations strive for quality improvement in clinical care and management. Besides clinical skills, the health care staff needs managerial skills to coordinate with various staff for a range of processes including human resource management, research activities, networking, and education. Meetings are usually the starting point for all these processes. Effective meetings and effective presentations are thus crucial to achieve the organisation’s goal. This chapter reviews the essentials of how to handle complaints, meetings, and presentations at workplace.