Mainstream end-tidal carbon dioxide monitoring in ventilated neonates

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Singapore Med J 2008; 49(3):199-203
Mainstream end-tidal carbon dioxide monitoring in ventilated neonates

Bhat YR, Abhishek N 
Correspondence: Dr Ramesh Bhat Y, docrameshbhat@yahoo.co.in


ABSTRACT
Introduction: Continuous noninvasive monitoring of the partial pressure of arterial carbon dioxide (PaCO2) in ventilated neonates would help clinicians to reduce arterial blood sampling. Our objective was to determine the correlation and agreement between end-tidal carbon dioxide (EtCO2) and PaCO2 in newborns ventilated for various clinical situations.
Methods: This prospective study was undertaken over 15 months in a teaching hospital. Simultaneous end-tidal and arterial CO2 pairs were obtained from ventilated neonates who were monitored by mainstream capnography and had indwelling arterial catheter. The correlation coefficient and degree of bias between EtCO2 and PaCO2 were assessed for various clinical situations.
Results: A total of 133 end-tidal and arterial CO2 pairs were analysed from 32 ventilated newborns. The mean gestational age was 34.6 +/- 3.8 weeks and birth weight was 2,200 +/- 780 g. The overall coefficient of correlation (r) was 0.73 (p-value is less than 0.001). The EtCO2 value was lower than the corresponding PaCO2 value in 86.5 percent pairs, with a mean bias of -6.65 +/- 7.54 mmHg (95 percent CI, - 7.9 to - 5.35). The r-value was more than or equal to 0.92 in neonates ventilated for sepsis, asphyxia and apnoea of prematurity, 0.67 in hyaline membrane disease (HMD) and 0.69 in meconium-aspiration syndrome. In HMD, neonates who received surfactant had a better r-value than those who did not (0.76 vs. 0.6).
Conclusion: The correlation between mainstream EtCO2 and PaCO2 is good. Neonates with pulmonary disease will have a lower correlation. Surfactant therapy improves the correlation. EtCO2 monitoring is helpful in trending or screening for abnormal PaCO2 values.
 
Keywords: arterial carbon dioxide monitoring, end-tidal carbon dioxide monitoring, mainstream capnography, mechanical ventilation, neonate ventilation
Singapore Med J 2008; 49(3):199-203

Predictors of newborn admission after labour induction at term: Bishop score, pre-induction ultrasonography and clinical risk factors

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Singapore Med J 2008; 49(3):193-8
Predictors of newborn admission after labour induction at term: Bishop score, pre-induction ultrasonography and clinical risk factors

Tan PC, Suguna S, Vallikkannu N, Hassan J
Correspondence: Dr Tan Peng Chiong, pctan@um.edu.my; tanpengchiong@yahoo.com


ABSTRACT
Introduction: Following labour induction at term, 12 percent of neonates can expected to be admitted to the neonatal intensive care unit. We aimed to evaluate the Bishop score, pre-induction ultrasonography (US) assessment of amniotic fluid, foetal weight and cervical length, and pre-induction and intrapartum risk factors as predictors of neonatal admission.
Methods: 152 women at term, scheduled for labour induction, consented to participate in this prospective study. Transabdominal US was performed to obtain foetal biometry and amniotic fluid index, followed by transvaginal US to measure cervical length. US findings were concealed. The Bishop score was obtained at initiation of labour induction. Pre-induction and intrapartum risk factors were also considered in the multivariate logistic regression analysis. All study women received standard care.
Results: On univariate analysis, factors associated with neonatal admission were: gestational age at less than or equal to 40 weeks, labour induction for diabetes mellitus, Bishop score of less than 5 at initiation of labour induction, estimated foetal weight of less than 2.5 kg by US, induction to delivery interval of more than 24 hours, caesarean delivery and umbilical cord blood pH of less than 7.1. Cervical length of greater than 20 mm on transvaginal US (p-value is 0.10) was not significant. After multivariate logistic regression analysis, controlling for the significant variables, only the unfavourable Bishop score (adjusted OR 4.2; 95% CI 1.2-13.8; p-value is 0.02) and caesarean delivery (adjusted OR 3.9; 95% CI 1.1-13.7; p-value is 0.035) were independent predictors of neonatal admission.
Conclusion: The identification of an unfavourable Bishop score as an independent predictor of neonatal admission is useful in the counselling of women who are considering labour induction.

Keywords: Bishop score, caesarean delivery,  labour induction, neonatal admission, obstetrical  ultrasonography
Singapore Med J 2008; 49(3):193-8

Predictors for caesarean delivery and neonatal admission after trial of labour in women with one previous lower segment caesarean scar

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Singapore Med J 2008; 49(3):188-92
Predictors for caesarean delivery and neonatal admission after trial of labour in women with one previous lower segment caesarean scar

Tan PC, Subramaniam RN, Omar SZ
Correspondence: Dr Tan Peng Chiong, pctan@um.edu.my; tanpengchiong@yahoo.com 


ABSTRACT
Introduction: Caesarean delivery rates are still increasing, and reliable predictors of adverse outcomes at a subsequent trial of scar are important as they guide decision-making on the best mode of delivery. We aimed to evaluate whether there are any predictors for caesarean delivery and neonatal admission, following trial of labour after one lower transverse caesarean section.
Methods: 768 women at term with singleton gestation and who had undergone a trial of labour between June 2002 and December 2005, were retrospectively identified using the labour ward register. 51 infants were admitted to a neonatal unit. Case notes for these cases were retrieved. Emergency repeat caesarean delivery and neonatal admission were the main outcome measures.
Results: Following multivariate logistic regression analysis, no previous vaginal birth (adjusted odds-ratio [AOR] 3.4), diabetes mellitus or hypertension in pregnancy (AOR 1.7), induction of labour (AOR 2.0), oxytocin use in labour (AOR 2.4), and meconium-stained liquor (AOR 4.9) were independent predictors of emergency caesarean delivery. Diabetes mellitus or hypertension in pregnancy (AOR 3.1), prelabour rupture of membranes (AOR 4.7) and caesarean delivery (AOR 6.0) were independent predictors of neonatal admission.
Conclusion: Predictors for emergency caesarean delivery and neonatal admission following a trial of labour can be identified. This information should be incorporated into the counselling of women contemplating a trial of labour. The strongest predictor for neonatal admission was emergency caesarean delivery, further emphasising the need for careful case selection in a trial of labour to minimise the risk of failure.
 

Keywords: emergency caesarean section,  meconium-stained liquor, neonatal admission,  prelabour rupture of membranes, trial of labour
Singapore Med J 2008; 49(3):188-192

Inpatient paediatric use of intravenous immunoglobulin at an academic medical centre

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Singapore Med J 2008; 49(2):147-9
Inpatient paediatric use of intravenous immunoglobulin at an academic medical centre

Dashti-Khavidaki S, Khalili H, Farshadi F, Aghamohammadi A, Movahedi M, Hajibabaei M 
Correspondence: Dr Hossein Khalili, khalilih@sina.tums.ac.ir


ABSTRACT
Introduction Intravenous immunoglobulin (IVIG) is an important research topic because of its efficacy in the management of an increasing number of diseases, its high cost and limited availability. This study was designed to evaluate the paediatric inpatient use of IVIG and identify strategies to reduce the drug expenditures.
Methods Over a six-month period, physician and nursing charts, and notes for subjects who were treated with IVIG, were reviewed to gather the required data. This included patient demographics, IVIG, indications, dosage regimen, adverse drug reactions (ADRs) and their management.
Results 58.3 percent of IVIG infusions were ordered for labelled indications. Patients in the labelled group experienced more clinical improvement than subjects in the off-label group. Haematologists and neurologists were the most prevalent prescribers. ADRs were more prevalent in the off-label group. Hypotension, fever, headache and chills were the most common adverse effects. ADRs were managed with drugs in 22.9 percent of IVIG administrations and IVIG infusions were modified in 12.5 percent of infusions.
Conclusion ADRs were more prevalent in this hospital than those reported by other authors. This may be due to nursing negligence of the recommended infusion rate, higher sensitivity of our population or to the brands of IVIG which are used in the hospital. This shows the need for further evaluation of IVIG prescription and administration.
 

Keywords: adverse drug reactions, drug utilisation review, intravenous immunoglobulin
Singapore Med J 2008; 49(2):147-9

Digital imaging by parents: an aid to the diagnosis of inguinal hernia in infants and children

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Singapore Med J 2008; 49(2):145-6
Digital imaging by parents: an aid to the diagnosis of inguinal hernia in infants and children

Saleem MM
Correspondence: Dr Mohammad M Saleem, mohomari@hotmail.com 


ABSTRACT
Introduction The aim of the study is to see the feasibility of utilisation of digital imaging by parents in the diagnosis of inguinal hernia in children, and reduce the rate of occasional negative groin exploration.
Methods During a two and a half year period, 155 inguinal hernias were diagnosed and operated on in our university teaching hospital. The diagnosis was based on the history and physical examinations of all patients. In 21 patients, the diagnosis was made based on the examination of history alone, as they did not demonstrate the hernia at presentation. In the last year, digital imaging by parents was utilised to aid in the diagnosis of difficult cases. There were ten cases, in addition to the history and physical examinations, that were confirmed by this method. All hernias were confirmed at exploration during surgery.
Results Out of 155 inguinal hernias, 21 (13.5 percent) were diagnosed by history alone, of which four (2.5 percent) had negative exploration, eight (5.1 percent) were positive for hernia, supported with digital imaging by parents' pictures, and nine (5.8 percent) were positive at exploration, without any additional means of diagnosis.
Conclusion History-taking and physical examinations are the mainstay of diagnosis of inguinal hernia in children. The capture of a digital image of the presenting complaint by the patients' parents, can be used as an additional aid in the diagnosis of difficult cases to demonstrate inguinal hernia, as demonstrated in a selected group of children.
 

Keywords: diagnosis of inguinal hernia, digital  imaging, inguinal hernia, parents
Singapore Med J 2008; 49(2):145-6

Early outcome of congenital diaphragmatic hernia in a Malaysian tertiary centre

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Singapore Med J 2008; 49(2):142-4
Early outcome of congenital diaphragmatic hernia in a Malaysian tertiary centre

Rohana J, Boo NY, Thambidorai CR
Correspondence: Dr Rohana Jaafar, drohana@mail.hukm.ukm.my


ABSTRACT
Introduction This prospective observational study was conducted to determine the outcome of newborns with congenital diaphragmatic hernia (CDH). They were managed with a protocol of gentle ventilation to avoid barotraumas, and inhaled nitric oxide (iNO) or intravenous magnesium sulphate for treatment of persistent pulmonary hypertension of newborns (PPHN).
Methods All newborns with CDH admitted to neonatal intensive care unit of this hospital during the six-year study period were recruited. High frequency oscillatory ventilation was used when infants required peak inspiratory pressure of more than 25 mmHg. iNO at 20 ppm or intravenous magnesium sulphate was used when PPHN developed. Arterial blood pH was maintained between 7.35 and 7.45, and partial pressure of arterial carbon dioxide was kept above 35 mmHg. Surgery was performed when the infants' general condition and blood gases were stabilised for at least 24 hours.
Results Of 21 infants recruited (15 males and six females, median gestational age 39.0 weeks, median birth weight 2,800 grams), 52.4 percent had PPHN. 12 (57.1 percent) underwent surgery at a median age of 4.9 days. One died postoperatively due to PPHN. Out of the 21 subjects, 11 (52.4 percent) survived to discharge. There was no significant difference in the demographic characteristics, side and size of CDH defects, presence of PPHN, or type of treatment received, between infants who survived and died. However, infants who died had significantly lower mean Apgar scores at five minutes of life (p-value is 0.02), and higher mean oxygenation indexes (OI) (p-value is 0.01) than those of survivors. Two (18.2 percent) of the 11 survivors developed chronic lung disease.
Conclusion Low Apgar scores and high OI were associated with poor outcome in infants with CDH.

Keywords: congenital diaphragmatic hernia, inhaled nitric oxide, magnesium sulphate, persistent pulmonary hypertension of newborns
Singapore Med J 2008; 49(2):142-4

Antihyperglycaemic and antihyperlipidaemic effects of Nymphaea stellata in alloxan-induced diabetic rats

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Singapore Med J 2008; 49(2):137-41
Antihyperglycaemic and antihyperlipidaemic effects of Nymphaea stellata in alloxan-induced diabetic rats

Rajagopal K, Sasikala K
Correspondence: Dr Rajagopal K, rajagopal_pharmacy@rediffmail.com


ABSTRACT
Introducion This study aims to investigate Nymphaea stellata (N. stellata) flower extract for antihyperglycaemic and antihyperlipidaemic effects in diabetic rats induced by alloxan. Its effect was compared with that of glibenclamide, a reference antidiabetic drug.
Methods Diabetic animals were randomly divided into five groups and treated orally with different doses (200, 300 and 400 mg/kg body weight) of flower extract once a day for 30 days. The body weight of each animal was determined, to assess any possible weight gain or loss in experimental animals compared with control groups. On the 31st day, those administered 300 mg/kg of N. stellata flower showed more promising results with regard to fasting blood glucose (FBG), plasma insulin levels, haemoglobin counts, urine sugar levels, food intake, water intake, urea and protein when compared to those treated with other doses. Therefore, 300 mg/kg dose was used for further biochemical studies. Total lipids (TL), total cholesterol (TC), triglycerides (TG), phospholipids, free fatty acids (FFA), low density lipoproteins (LDL), very low density lipoproteins (VLDL), atherogenic index (AI) and high density lipoproteins (HDL) levels, on normal and diabetic rats treated with the dose of 300 mg/kg, were evaluated.
Results The flower extract shows a significant (p-value is less than 0.001) reduction in levels of FBG, water intake, food intake, urine sugar, blood urea, TL, TC, TG, FFA, phospholipids, LDL, VLDL and AI. It also shows a significant increase in body weight, plasma insulin, protein, haemoglobin and HDL levels.
Conclusion Our results suggest that N. stellata flower extract exhibit antihyperglycaemic as well as antihyperlipidaemic effects on alloxan-induced diabetic rats.
 

Keywords: alloxan, antihyperglycaemic, diabetes mellitus, Nymphaea stellata flower extract
Singapore Med J 2008; 49(2):137-41

Blood lipid peroxidation (superoxide dismutase, malondialdehyde, glutathione) levels in Egyptian type 2 diabetic patients

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Singapore Med J 2008; 49(2):129-36
Blood lipid peroxidation (superoxide dismutase, malondialdehyde, glutathione) levels in Egyptian type 2 diabetic patients

Soliman GZ
Correspondence: Dr Ghada Zaghloul Abbas Soliman, amr_soliman2005@yahoo.com


ABSTRACT
Introduction The existence of hyperglycaemia produces increased oxidative stress. The depletion of antioxidants as a defensive body mechanism may increase the risk of diabetic complications. Diabetes mellitus is associated with derangements in the serum levels of several biochemical parameters, and type 2 diabetes mellitus (or non-insulin-dependent diabetes mellitus) is a risk factor for cardiovascular diseases.
Methods Data of 80 control subjects (male:female, 40:40) and 80 diabetic patients (male:female, 40:40), of similar age, gender, body mass index and duration of diabetes mellitus (for diabetic group), were collected from government and non-government organisations during the period, 2001-2004. Blood samples were also collected. Glucose, glucosylated haemoglobin, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDLC), TC/HDL-C, HDL-C/LDL-C, triacylglycerol, malondialdehyde, glutathione and superoxide dismutase levels were determined.
Results Mean cholesterol, LDL-C, VLDL-C and triacylglycerol levels were significantly higher in patients with type 2 diabetes mellitus in comparison to the control subjects, while the mean value of HDL-C was significantly lower. A significant elevation in malondialdehyde level and decrease in glutathione content were observed in both male and female diabetic patients in comparison to the control subjects.
Conclusion The results suggest that the increase in lipid peroxidation, and the decline in antioxidant defences, may appear early in type 2 diabetic patients, before the development of secondary complications. This phenomenon might play an important role in the initiation and progression of diabetic complications. Our results also suggest that there seems to be an imbalance between plasma oxidant and antioxidant systems in patients with type 2 diabetes mellitus.
 

Keywords: diabetes mellitus, glutathione, lipoproteins, malondialdehyde, non-insulindependent diabetes mellitus, superoxide dismutase
Singapore Med J 2008; 49(2):129-36

Independent predictors of cardiac parasympathetic dysfunction in type 2 diabetes mellitus

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Singapore Med J 2008; 49(2):121-8
Independent predictors of cardiac parasympathetic dysfunction in type 2 diabetes mellitus

Subbalakshmi NK, Adhikari PM, Rajeev A, Asha K, Jeganathan PS
Correspondence: Dr Subbalakshmi NK, rao.subbalakshmink@rediffmail.com


ABSTRACT
Introduction Although the clinical implications of diabetic autonomic neuropathy have been described, the clinical determinants of parasympathetic dysfunction in type 2 diabetes mellitus are not clear. We investigated the clinical determinants of heart rate response to deep breathing in type 2 diabetes mellitus.
Methods This study involved 207 randomly selected patients with type 2 diabetes mellitus and 141 healthy controls. Heart rate response to deep breathing was measured in all the subjects. Heart rate response to Valsalva manoeuvre and active standing was measured in lesser numbers. Data analysis was done using unpaired Student's t-test, Pearson's correlation test and multiple regression.
Results Heart rate response to deep breathing, Valsalva manoeuvre and active standing was lower in patients with diabetes mellitus than in controls (p-value is less than 0.0001, 0.01 and 0.01, respectively). Age, female gender and presence of somatic neuropathy were the independent predictors of reduced heart rate response to deep breathing (p-value is 0.001). Independent positive correlation was found between resting heart rate and heart response to deep breathing (p-value is 0.02). Factors associated with depressed heart rate response to deep breathing, but not independently predictive, were duration of diabetes mellitus, presence of hypertension, coronary artery disease, foot ulcer and retinopathy. Mean heart rate response to deep breathing of 47 patients with diabetes mellitus free of all complications was lower compared to controls (p-value is less than 0.01).
Conclusion Our data suggests that parasympathetic dysfunction mainly coexists with somatic neuropathy. It may be isolated, or precede detection of other complications. Age and female gender are the other predictors of reduced heart rate response to deep breathing in type 2 diabetes mellitus.

Keywords: diabetes mellitus, heart rate variation, parasympathetic dysfunction, somatic neuropathy, type 2 diabetes mellitus
Singapore Med J 2008; 49(2):121-8

Comparison of serum F2 isoprostane levels in diabetic patients and diabetic patients infected with Burkholderia pseudomallei

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Singapore Med J 2008; 49(2):117-20
Comparison of serum F2 isoprostane levels in diabetic patients and diabetic patients infected with Burkholderia pseudomallei

Puthucheary SD, Nathan SA
Correspondence: Prof SD Puthucheary, puthu@um.edu.my


ABSTRACT
Introduction Oxidative stress can occur in sepsis and infection, when overproduction of free radicals is not countered by the host antioxidant system, leading to impairment of host cellular functions. Various disease states are accompanied by the accumulation of 15-F2t-IsoP in biological fluids. These isoprostanes are considered as markers of oxidative stress, and inflammation and inflammatory mediators.
Methods We measured total serum 15-F2t-IsoP levels by the immunoassay method in healthy adults, otherwise healthy patients with diabetes mellitus and diabetic patients infected with Burkholderia pseudomallei (B. pseudomallei).
Results The highest mean value of 4,343.6 pg/ml of 15-F2t-IsoP was found in the diabetic melioidosis patients in comparison with the uninfected diabetic patients and the normal controls. Uninfected diabetic patients had significantly higher levels than the control subjects (p-value is less than 0.001), but lower than the diabetic-melioidosis patients (p-value is less than 0.001). The main finding of the present study was an eight-times higher median circulating total IsoPs levels in diabetic patients infected with B. pseudomallei when compared with the levels in control subjects.
Conclusion The oxidative stress theory proposes that severe sepsis leads to activation of neutrophils and macrophages which subsequently release reactive oxygen-free radicals that may result in lipid peroxidation of endothelial and epithelial cell membrane phospholipids. This chain reaction results in increased levels of isoprostanes, which are thought to contribute to much of the end-stage tissue damage seen in serious infections, such as melioidosis. We believe that this is the first report linking in vivo oxidative stress status and diabetic patients infected with B. pseudomallei.
 

Keywords: Burkholderia pseudomallei, diabetes mellitus, F2 isoprostanes, immunoassay
Singapore Med J 2008 Feb;49(2):117-20