Efficacy of a low cost protocol in reducing noise levels in the neonatal intensive care unit

Objective  To examine the effectiveness and cost of implementing a noise reduction protocol in a level III neonatal intensive care unit (NICU). Methods  A prospective longitudinal study was done in a level III NICU, wherein a noise reduction protocol that included behavioral and environmental modification was implemented. The noise levels were measured sequentially every hour for 15 days before and after this intervention. The statistical significance of the reduction in noise levels after implementation of the protocol was tested by paired sample student’s t-test. Cost was calculated using the generalized cost effectiveness model of the World Health Organisation. The present study has 80 % power with 95 % confidence to measure 2 dB differences between groups for the maximum recommended of 50 dB. Results  The protocol in the present study reduced noise levels in all the rooms of the NICU to within 60 dB with high statistical significance (p< 0.001). The extent of noise reduction in the rooms of the NICU was as follows: ventilator room by 9.58 dB (95 % confidence interval: 6.73–12.42, p < 0.001), stable room by 6.54 dB (95 % confidence interval: 2.92–4.16, p < 0.001), isolation room by 2.26 dB (95 % confidence interval: 1.21–3.30, p < 0.001), pre-term room by 2.37 dB(95 % confidence interval: 1.22–3.51, p < 0.001) and extreme preterm room by 2.09 dB (95 % confidence interval: 1.14–3.02, p < 0.001). The intervention was most cost-effective in the ventilator room, requiring Rs. 81.09 to reduce 1 dB and least effective in the extreme pre-term room requiring Rs. 371.61 to reduce 1 dB. Conclusion  The high efficacy and affordability of noise reduction protocols justify the need for implementation of these measures as a standard of care in neonatal intensive care units.     

Universal hearing screening

Objective To determine the weighted incidence of hearing impairment in a standardized population of at risk and not at risk neonates seeking care at a tertiary level hospital in India. Methods A prospective study of a nonrandomized cohort of 1769 neonates (1490: Not at risk; 279: At risk) from a total of 8192 neonates (6509: Not at risk; 1683: At risk) who sought care at St John’s medical College hospital from 1^st September 2002 to 31^st March 2006 were screened for hearing impairment using transient evoked otoacoustic emissions. Weighting was performed using the expected value of 10 % at risk and 90 % not at risk infants in a typical tertiary care level center in India derived from the National Neonatology and Perinatology database 2002–2003. Z test and 95 % confidence interval was used to determine the external validity of the results. P less than 0.05 was considered as statistically significant. The power of the study is 90 %. Results The incidence of hearing impairment in infants screened was 10 per 1769 infants screened (1490: Not at risk; 279: At risk) which is 5.65 per 1000 screened. 279 at risk infants were screened and 3 were detected to have hearing impairment which is an incidence of approximately 10.75 per 1000 screened. Of the 1490 not at risk infants screened 7 had hearing impairment that is 4.70 per 1000 screened. If this was extrapolated to a standardized population consisting of 10 % at risk and 90 % not at risk then the incidence would be 5.60 per 1000 screened with a 95 % confidence interval of 4.13–7.06. This narrow 95 % confidence interval with a p equal to 0.001 indicates that this value may be close to the caseload in a typical tertiary care center. Conclusion In this study the incidence of hearing impairment is 3 per 279 in at risk infants screened and 7 per 1490 in not at risk infants screened. The weighted incidence in a standardized population of neonates seeking care at tertiary level center in India is 5.60 per 1000 as per this study. This high incidence calls for all pediatricians to consider incorporating a basic hearing screen for all the neonates using cost effective and appropriate technology. Initial screening may be performed using behavioral observation techniques and confirmation by otoacoustic emissions.     

A neutral technetium-99m complex for myocardial imaging

Technetium-99m-CDO-MeB [Bis[1,2-cyclohexanedione-dioximato(1-)- O]-[1,2-cyclohexanedione dioximato(2-)-O]methyl-borato(2-)- N,N',N',N',N',N'')-chlorotechnetium) belongs to a family of compounds generally known as boronic acid adducts of technetium dioxime complexes (BATOs). It has an intrinsic affinity for the myocardium, with negligible lung activity and rapid blood clearance. The uptake of 3.44% ID in rat heart at 1 min postinjection for [99mTc]CDO-MeB versus 3.03% for 201TI indicates high extraction of [99mTc]CDO-MeB by the myocardium. In dogs an ischemic defect is clearly seen in SPECT images obtained 10 min after injection of [99mTc]CDO-MeB. Tissue distribution data in rats show that [99mTc]CDO-MeB is excreted primarily in the feces and to a lesser extent in the urine. Approximately 80% of the activity is excreted within 24 hr after injection.     

Three-dimensional finite element analysis of the pediatric lumbar spine. Part I: pathomechanism of apophyseal bony ring fracture

The purpose of this study was to (1) develop a three-dimensional, nonlinear pediatric lumbar spine finite element model (FEM), and (2) identify the mechanical reasons for the posterior apophyseal bony ring fracture in the pediatric patients. The pediatric spine FE model was created from an experimentally validated three-dimensional adult lumbar spine FEM. The size of the FEM was reduced to 96% taking into account of the ratio of the sitting height of an average 14-years-old children to that of an adult. The pediatric spine was created with anatomically specific features like the growth plate and the apophyseal bony ring. For the stress analyses, a 10-N m moment was applied in all the six directions of motion for the lumbar spine. A preload of 351 N was applied which corresponds to the mean body weight of the 14-years-old group. The stresses at the apophyseal bony ring, growth plate and endplate were calculated. The results indicate that the structures surrounding the growth plate including apophyseal bony ring and osseous endplate were highly stressed, as compared to other structures. Furthermore, posterior structures in extension were in compression whereas in flexion they were in tension, with magnitude of stresses higher in extension than in flexion. Over time, the higher compression stresses along with tension stresses in flexion may contribute to the apophyseal ring fracture (fatigue phenomena).Part II of this article can be found at .     

Psychological contributors to the frail phenotype: The association between resilience and frailty in patients with cirrhosis

We examined whether a key psychological trait—resilience, defined as one's ability to recover quickly from difficulties—contributes to the frail phenotype in patients with cirrhosis. Included were 300 adult patients with cirrhosis who underwent outpatient physical frailty testing using the Liver Frailty Index and resilience testing using the Connor-Davidson Resilience Scale (CD-RISC). The Liver Frailty Index was categorized as robust, prefrail-robust, prefrail-frail, and frail; CD-RISC was categorized using population norms as: least, less, more, and most resilient. Linear regression was used to assess factors associated with frailty (by the Liver Frailty Index per 0.1 unit change). Among the most resilient, only 10% were frail; among the least resilient, 29% were frail. In univariable analysis, resilience was strongly associated with the Liver Frailty Index (coef = −0.13 per point increase; 95% confidence interval [CI], −0.20 to −0.60; P < .001) and remained significantly associated with frailty in multivariable adjustment (coef = −0.13, 95% CI −0.19 to −0.07; P < .001). Low resilience is strongly associated with the frail phenotype in patients with cirrhosis. Given that resilience is modifiable, our data suggest that effective interventions to mitigate frailty should include strategies to build resilience in patients with low baseline resilience.     

Gingival biotype — Prosthodontic perspective

During treatment planning it is important to recognize different gingival biotypes and forms, because they can affect the esthetic outcome of the treatment. This review provides an insight into the different gingival biotypes, their response to inflammation and trauma; significance in different prosthodontic modalities like esthetic rehabilitation and implant therapy.     

Cayler Cardio-Facial Syndrome: An Uncommon Condition in Newborns

Introduction:

Cayler cardio-facial syndrome is a rare syndrome associated with asymmetric crying faces with congenital heart disease. We report a newborn that was diagnosed as case of Cayler Cardio-facial syndrome based on clinical features and was confirmed with FISH analysis.

Case Presentation:

A term male baby, born to non-consanguineous couple through normal vaginal delivery was diagnosed to have asymmetric crying faces with deviation of angle of mouth to left side at the time of birth. The baby had normal faces while sleeping or silent. Mother was known case of hypothyroidism and was on treatment. Baby was diagnosed as case of Cayler Cardio-facial Syndrome and was investigated with echocardiogram, brain ultrasound, total body X-ray examination, X-ray of cervico-thoracic vertebral column and fundus examination. Echocardiogram showed muscular VSD, brain ultrasound was normal and fundus examination showed tortuous retinal vessels. Whole body X-ray and lateral X-ray of cervico-thoracic vertebral column were not suggestive of any skeletal abnormalities. The other associated malformation was right ear microtia. Baby FISH karyotype analysis showed deletion of 22q11.2 deletion. Baby was discharged and now on follow-up.

Conclusions:

Cayler syndrome is a rare syndrome which must be suspected if a baby has asymmetrical cry pattern and normal facies when baby sleeps. Patient must be evaluated with echocardiography to find out associated cardiac malformations. These infants should undergo FISH analysis for 22q11.2 deletion syndrome.     

Abdominal pain secondary to stump appendicitis in a child

We report a case of an 11-year-old male who presented with abdominal pain and vomiting. The patient had a notable past medical history of having had an appendectomy at our institution 1 year previously. Because of progressive clinical signs of peritonitis, an exploratory laparotomy was performed and the patient was found to have stump appendicitis. The entity of stump appendicitis is always possible when evaluating patients with abdominal pain who have a history of appendectomy.     

A four-step technique of robotic right adrenalectomy: initial experience

OBJECTIVE

To report a safe, quick and reproducible technique of robotically assisted right adrenalectomy (RRA), developed by assessing the surgical anatomy of the right adrenal gland, its vascularity, and the surrounding structures, through a high definition, magnified three‐dimensional view of the operating field provided by the da Vinci® surgical system (Intuitive Surgical, Sunnyville CA, USA).

PATIENTS AND METHODS

Four patients had RRA between January and July 2007 at the Vattikuti Urology Institute, for varied indications. We extensively reviewed published anatomical and surgical reports of the anatomy of the region to plan the surgical steps for RRA, careful reconfirming recognized anatomical facts and their probable significance. The surgical steps involved: (i) complete division of the hepatocolic ligament; (ii) definition of the right adreno‐caval junction (ACJ); (iii) division of the right adrenal vein; (iv) dissection and removal of the adrenal gland circumferentially. The surgery was digitally recorded and reviewed.

RESULTS

All the adrenalectomies were done transperitoneally through five ports, replicating predetermined surgical steps. There were no anaesthesia or surgery related events and no patient required conversion to open surgery. All the patients had an uneventful recovery and were discharged home 0–3 days after RRA. With increasing experience it was possible to reach the ACJ with minimal peripheral dissection. From a lateral approach, we visualized the adrenal vein travelling along the anterior portion of the gland before terminating at the inferior vena cava and the retrocaval location of the medial edge of the adrenal gland. The right adrenal vein (singular or duplicate) was the only surgically significant vessel, as the other vessels encountered were controlled with bipolar diathermy.

CONCLUSIONS

Robotic assistance facilitated microdissection of fine anatomical planes around the right adrenal gland and provided direct access to the crucial ACJ. This technique permits ligation of the adrenal vein as an initial step, with no need to handle the adrenal gland. In the initial experience with four patients this technique was reproducible, regardless of indication or anatomical variance.