AIM:The etiology, clinical impact, natural history and best therapy of unilateral diaphragm paralysis (UDP) are incompletely understood. This condition is not amenable to pacing, which requires an intact phrenic nerve.METHODS:Clinical records of patients with UDP referred to our diaphragm center were reviewed.RESULTS:Thirty-six patients (28 male, 8 female) aged 1 month to 78 years (mean 47.8 years) with UDP evaluated from 1983 to February 2007 were reviewed. Etiology was postsurgical in 13 (36%), tumor (with surgery or radiation therapy) in 7 (19%), idiopathic in 6 (17%), trauma (motor vehicle accident or head injury) in 5 (14%), polio in 3 (8%), and viral in 2 (6%) patients. 28 patients (78%) were symptomatic; 8 (22%) carried a diagnosis of coexisting chronic obstructive pulmonary disease. Mean duration of paralysis was 57.9 months (range up to 261 months). The left diaphragm was involved in 23 cases (64%) and the right in 13 (36%). Mean forced expiratory volume (FEV1) was 1 915 mL (61.3% of predicted) and mean forced vital capacity (FVC) was 2 432 mL (62.9% of predicted). Mean pO2 was 69.9 mmHg (range 49 to 124), indicating considerable shunting through underventilated lung. Pulmonary infection affected 3 patients (8.4%). Diaphragm function returned in 17% of patients (mainly children) at mean of 10.3 months. Four incapacitated patients (11 %) were treated surgically, with resection of the hemi-diaphragm. Surgical exploration revealed neurogenic atrophy of the diaphragm muscle. All 4 resected patients showed clinical, oxymetric, and spirometric improvement.CONCLUSION:The conclusion is drawn that: 1) UDP may be traumatic, tumor-related, iatrogenic, or idiopathic; 2) UDP decreases pO(2) substantially and breathing capacity by more than 1/3; 3) spontaneous recovery is possible; 4) UDP is not intrinsically lethal; 5) occasional patients are incapacited; 6) diaphragm resection produces clinical improvement via lower lobe re-expansion; 7) the incapacity incurred by UDP is mild compared to the clinical spectrum of bilateral diaphragm paralysis.

The impact of a neonatal resuscitation programme (NRP) on the incidence, management and outcome of birth asphyxia was evaluated in 14 teaching hospitals in India. Two faculty members from each institution attended a neonatal resuscitation certification course and afterwards trained staff in their respective hospitals. Each institution provided 3 months pre-intervention and 12 months post-intervention data. Introduction of the NRP significantly increased awareness and documentation of birth asphyxia, as judged by an increased incidence of asphyxia based on apnoea or gasping at 1 and 5 minutes (p < 0.001 and < 0.01, respectively). A significant shift towards more rational resuscitation practices was indicated by a decline in the use of chest compression and medication (p < 0.001 for each), and an increase in the use of bag and mask ventilation (p < 0.001). Although overall neonatal mortality did not decrease, asphyxia-related deaths declined significantly (p < 0.01).

A prospective study was undertaken on the incidence of intrauterine infections by screening 1302 cord blood samples for total IgM by radial immunodiffusion. Specific IgM against cytomegalovirus (CMV), rubella and Toxoplasma were estimated in cord blood samples found to contain total IgM > 20 mg/dl. All these neonates were examined at birth and at discharge. Cord blood samples with total IgM > 20 mg/dl were further screened for specific IgM against rubella, CMV and Toxoplasma. Neonates found to have positive specific IgM were followed-up for hearing, opthalmological and developmental assessment. Raised cord blood (IgM > 20 mg/dl) was found in 270/1302 (20.6 per cent). Mean birth weight was comparable in babies with raised (> 20 mg/dl) or low (< 20 mg/dl) cord blood total IgM. Incidence of prematurity and low birth weight were not statistically different in babies with raised cord blood IgM when compared to those with low cord blood IgM levels. Similarly, incidence of intrauterine growth retardation (IUGR) idiopathic was similar in two groups. Specific IgM for rubella was found to be positive in eight (0.6 per cent). Of these, three had symptomatic rubella infection. Two mothers of these symptomatic babies had exanthematous viral illness during first trimester. Specific IgM for CMV was found to be positive in 23 (1.8 per cent) while two infants had symptomatic CMV disease. None of the babies was found to have specific IgM against Toxoplasma. One baby with symptomatic CMV disease and one with rubella died. Another baby with symptomatic CMV disease developed neonatal hepatitis which improved on follow-up but the infant went on to develop sensorineural deafness. All other asymptomatic babies with specific IgM positive against rubella and CMV were found to have normal vision, hearing and development on follow-up.

Aim-To assess the cell mediated immune response to BCG vaccine in preterm babies.Methods-Sixty two consecutive preterm babies born at < 35 weeks of gestation were randomly allocated into two groups. Babies in group A were vaccinated early at 34-35 weeks and group B were vaccinated late at 38-40 weeks of postconceptional age. The two groups were similar in terms of: gestational age (mean (SD) 33.1(1.1) and 33 (1.2) weeks, respectively); birthweight 1583 (204) and 1546 (218) g; neonatal problems; socioeconomic status; and postnatal weight gain. The cell mediated immune response to BCG was assessed using the Mantoux test and the lymphocyte migration inhibition test (LMIT) 6-8 weeks after BCG vaccination. Induration of >5 mm after the Mantoux test was taken as a positive response.Results-There was no significant difference in the tuberculin conversion rates (80% and 80.7%, respectively), positive LMIT (86.6% and 90.3%, respectively), or BCG scar (90.0% and 87.1%, respectively) among the two groups.Conclusions-Prematurity seems to be an unlikely cause for poor vaccine uptake. Preterm babies can be effectively vaccinated with BCG at 34-35 weeks of postconceptional age, the normal time of discharge in a developing country.

OBJECTIVETo evaluate whether prophylactic use of cisapride will reduce the incidence of feed intolerance and gastro-esophageal reflux, and improve gastric emptying in early neonatal period in preterm babies.DESIGNDouble blind randomized controlled trial.SETTINGHospital based.SUBJECTSForty nine preterm babies between 29-34 weeks of gestation were administered either cisapride or placebo.METHODSBabies were enrolled in the study once they reached 30 ml/kg/day of enteral feeding or when 25% of total fluid intake was received through the enteral route. Those with sepsis, congenital malformations and on aminophylline were excluded. The subjects were randomized to receive either cisapride or placebo in a dose of 0.2 mg/kg/dose every 8 hourly for 14 days or till discharge. During the study period babies were observed for clinical signs of feed intolerance as judged by increase in abdominal girth, increased prefeed gastric residuals or vomiting. Gastro-esophageal reflux and gastric emptying time was assessed by Technetium phytate scan on day 7 +/- 1.RESULTSFeed intolerance was noticed in 59% of study and 41% of control population. No significant difference was noticed in the two groups in the total number of episodes of feed intolerance (1.54 +/- 2.4 vs 1.18 +/- 1.6). Nearly 50% of babies in each group had gastro-esophageal reflux. Gastric emptying time (mean (SD) and median) was found to be comparable (p = 0.70) in those on drug and placebo (58.1 (32.2 min) 48.8 min) vs (53.8 (34.6 min) 43.4 min).CONCLUSIONCisapride does not reduce the incidence of feed intolerance, gastro-esophageal reflux and does not improve gastric emptying in normal preterm neonates.

BACKGROUND:Chlamydia trachomatis infection in pregnant women is suspected to result in low birth-weight and premature infants. We conducted studies to ascertain the prevalence of this infection among pregnant women in our setting and whether its presence is a risk factor for low birth-weight or prematurity.METHODS:In the first study, 94 pregnant women between 26 and 30 weeks of gestation were screened for infection with Chlamydia trachomatis. The second investigated a cohort of 172 pregnant women presenting in spontaneous labour. The infection status was related to perinatal outcome in terms of birth-weight and gestation. In both the studies, Chlamydia trachomatis infection was diagnosed using the Chlamydiazyme test performed on endocervical swabs.RESULTS:The prevalence of Chlamydia trachomatis infection in mid-pregnancy and at labour was 17% (16/94) and 18.6% (32/172), respectively. Women with infection were relatively older than those without it [mean (SD) age: 26.6 (4.5) years v. 24.8 (3.6) years, p = 0.01]. The mean (SD) birth-weight [2869 (611) g v. 2814 (496) g], gestation [38.5 (2.6) weeks v. 38.3 (2.0) weeks], and incidence of low birth-weight [18.7% v. 20.7%] as well as prematurity [9.4% v. 10.7%] were similar among neonates born to women with or without infection. Neonates born to infected mothers experienced purulent conjunctivitis more frequently than those born to non-infected mothers [12.5% v. 2.8%, p = 0.04].CONCLUSION:Chlamydia trachomatis is a relatively common infection in pregnant women. However, it was not associated with either low birth-weight or prematurity.

PROBLEM:Phase II clinical trials with the heterospecies dimer of beta hCG and alpha-subunit of ovine luteinizing hormone (HSD)-human chorionic gonadotrophin (hCG) vaccine showed that pregnancy was prevented at and above 50 ng/ml titers, whereas conceptions occurred below 35 ng/ml of hCG bioneutralization capacity. The effect of below-protective threshold anti-hCG antibodies on the progression of pregnancy and the normality of progeny was studied.METHOD OF STUDY:Four women enrolled by informed consent in the Phase II trials. The women studied were immunized with the HCG vaccine and did not receive booster injections in consideration of their desire to have another child. They were examined clinically at least once every month until delivery. The babies were followed up from 2 to 3.5 years, and their anthropometric indices were compared with elder siblings.RESULTS:The pregnancies progressed to 35 to 38 weeks with the usual obstetric problems, and the children developed normally.CONCLUSIONS:The anti-fertility effect of the HSD-hCG vaccine is reversible and low titers of antibodies below the protective threshold have no apparent side effects on the progression of pregnancy and on the early development of the progeny.

A randomized controlled trial was done to compare seroconversion following a single dose of trivalent oral polio vaccine (TOPV) in preterm babies, vaccinated at two different post-conception ages, with that of term newborns. Sixty-two consecutive preterm babies < or = 35 weeks were randomly allocated to two groups. Group A was vaccinated 'early' at 34-35 weeks and group B 'late' at 38-40 weeks post conception. The two groups were comparable in birthweight [mean (SD) 1594 g (118) and 1599 g (126), respectively] and gestational age [mean (SD) 33.2 (1.2) and 33 (1.3) weeks, respectively]. A control group of 36 term babies (group C) were vaccinated in the 1st week of life. Polio virus antibodies were measured immediately before and 6-8 weeks after vaccination. Group A had seroconversion rates of 54.2, 12.5 and 12.5% against polio virus types 1, 2 and 3, respectively, group B had rates of 60.0, 8.0 and 16.0%, and group C rates of 53.6, 10.7 and 14.3%. Differences in the seroconversion rates in the three groups were not statistically significant. The conversion rates against types 2 and 3 are much lower than in previous studies. We conclude that preterm babies vaccinated at 34-35 weeks post conception show seroconversion rates similar to those in term newborns.

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9+/-702 g vs 2737.8+/-500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P=0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

A randomized clinical trial was conducted to test the postulate that erythromycin treatment of pregnant mothers may prevent preterm deliveries and low birth weight (LBW) in India. Vaginal swabs (for Ureaplasma urealyticum and Mycoplasma hominis cultures) and endocervical specimens (for Chlamydia trachomatis antigen testing) were obtained from 437 pregnant women: 219 for the erythromycin group and 218 for the placebo group. Findings of the study showed that mean birth weight and the incidence of LBW and preterm deliveries in both groups were similar. This result is in opposition with the existing body of evidence that reports that infections in the genital tract caused by U. urealyticum and C. trachomatis may be associated with LBW and prematurity. The study therefore concludes that erythromycin treatment of pregnant women neither decreases the incidence of LBW or preterm deliveries nor will it improve birth weight of infants.

OBJECTIVE:This study was conducted to document the prevalence of maternal genital tract colonization by Ureaplasma urealyticum and Mycoplasma hominis, and to assess its association with low birth weight (LBW) and prematurity.METHODS:The high vaginal swabs of pregnant women in spontaneous labor after 26 weeks of gestation were cultured for U. urealyticum and M. hominis. Clinical details and perinatal outcomes including birth weight and gestation were documented.RESULTS:Of a total of 303 women enrolled, 148 (48.8%) had positive vaginal cultures for U. urealyticum, while only five (1.6%) grew M. hominis. The mean birth weight and the incidences of LBW and preterm neonates among ureaplasma positive and ureaplasma negative mothers were statistically comparable.CONCLUSIONS:U. urealyticum emerged as a common inhabitant of the lower genital tract of women in labor, being present in nearly half of them. Its presence was not a risk factor of LBW or prematurity. Maternal colonization with M. hominis was uncommon.

The bond of faith between a patient and his/her doctor is aptly summed up by Charaka: 'No other gift is greater than the gift of life! The patient may doubt his relatives, his sons and even his parents, but he has full faith in his physician. He gives himself up in the doctor's hands and has no misgivings about him. Therefore, it is the physician's duty to look after him as his own.' The doctor is still viewed as a demi-god and his advice and treatment accepted without questioning. To maintain this trust and faith, which is essential to augment the process of healing, it is incumbent upon physicians to be ethical, honest and up-to-date in their knowledge and approach towards patients under their care. The rapid strides in medical technology have unfolded complex medical, social, ethical, philosophical, moral and legal issues. It is a sad reality that physicians are allowing technology to de-humanize medicine. The focus has gradually shifted from the whole patient to his systems, organs, tissues, cells and even DNA! I Several physicians choose to treat laboratory reports rather than the patient in the wider context of his disease and social milieu. The chasm between cosmology, quantum healing and biology has widened.

India has an excellent infrastructural layout for the delivery of MCH services in the community through a network of subcenters, primary health centers, community health centers, district hospitals, state medical college hospitals, and other hospitals in the public and private sectors. However, the health pyramid does not function effectively because of limited resources, communication delays, a lack of commitment on the part of health professionals, and, above all, a lack of managerial skills, supervision, and political will. The allocation of financial resources for the delivery of health care continues to be meager. Nevertheless, in spite of obvious constraints, the country has made laudable progress in reducing post-neonatal mortality in recent years. Indeed, the focus has shifted to the young infants and the perinates. Under the CSSM program, a massive expansion of MCH services has occurred at the sub-district and the district levels. The RCH program, to be launched shortly, aims at effective utilization of these facilities to ensure delivery of integrated services of assured quality through decentralized planning. Simultaneously, as a result of the ongoing economic liberalization, the MCH care in the private sector will also expand rapidly. Indeed, India is on the threshold of an extraordinary improvement in the status of its neonatal-perinatal health.

BACKGROUND Birth asphyxia is a major cause of neonatal mortality. An understanding of the determinants of mortality among asphyxiated neonates will help formulate effective management protocols. METHODS One hundred and fifty consecutive neonates with birth asphyxia (apnoea or gasping respiration at 1-minute of age) were prospectively studied. The association of the outcome variable, namely, mortality before discharge, was documented in relation to a number of clinically important risk factors. RESULTS The neonatal mortality of 24.7% (37/150) among asphyxiated neonates was 34.5-times compared to that of the non-asphyxiated population (p < 0.001). The mortality rates in preterm-and term-asphyxiated neonates were 47.8% and 6%, respectively (p < 0.0001). The relative risk of mortality increased progressively with increased birth-weight. On univariate analysis, prematurity, low birth-weight, respiratory distress, severity of asphyxia, hypoxic-ischaemic encephalopathy, apnoea, acidosis and seizures were found to be significant risk factors of death. However, on step wise regression analysis, prematurity emerged as the most significant determinant of mortality. The highest positive predictive value (58.3%) for mortality was documented for hypoxic-ischaemic encephalopathy. CONCLUSION A significant reduction in mortality among asphyxiated neonates will require aggressive management of prematurity-related neonatal complications and hypoxic-ischaemic encephalopathy.

Vitamin K is needed to synthesize coagulation factors II (prothrombin), VII, IX, and X through the carboxylation of glutamic acid in vitamin K-dependent proteins which results in the creation of effective calcium binding sites which, in turn, facilitates the coagulation process. Vitamin K exists as naturally occurring vitamin K-I (phylloquinone) in green leafy vegetables and vegetable oils, vitamin K-II (menaquinone) as produced in the gut by bacteroides fragilis and E. coli, and synthetic vitamin K-III (menadoine sodium bisulfite) which is water-soluble and capable of producing serious jaundice in newborns, especially those with instability of glutathione and deficiency of G6PD. Humans require about 5 mcg of vitamin K daily. Since it is indigenously produced in the gut by bacterial flora, dietary deficiency of vitamin K in healthy subjects is rare. Vitamin K is usually the first vitamin given at birth. Newborn babies, however, absorb only approximately 30% of ingested vitamin K, compared to 50-70% in adults. Hemorrhagic disease is a manifestation of vitamin K deficiency in newborn infants. Hemorrhagic disease of the newborn (HDN), early HDN, classical HDN, and late HDN are discussed. The American Academy of Pediatrics recommended in 1961 that all healthy term newborn babies receive 0.5-1.0 mg of vitamin K-I intramuscularly at birth. However, while the authors have not followed those recommendations in their neonatal unit for 15 years, they have experienced only a 0.1% incidence of classical HDN. High-risk newborns at the unit are routinely given the recommended dose of K-I at birth.