Infrared Thermal Imaging to Detect Inflammatory Intra-Abdominal Pathology in Infants

A thermal imaging method to detect inflammatory intra-abdominal pathology in infants is proposed and evaluated through a clinical trial. Nine surgical infants, mean chronological age 58 days old (range: 21-83 days), mean weight 2.65 kg (range: 2.45-3.15 kg) with abdominal pathologies were included in the analysis. Infrared thermal image processing consisted of selecting the surgical region of interest where the area of abdominal inflammation was most likely to be, and an abdominal reference region on the same infant, with the aid of clustering segmentation. Skewness was found to be the most sensitive variable to significantly differentiate between the surgical region and reference region (p = 0.022). Multilinear regression analysis indicated that the relationship between the temperature difference signified by skewness and the patients' demographic information (age at time of imaging, gestational age at birth, weight at the time of imaging, birthweight, last stool prior to imaging and last oral intake prior to imaging) was not significant. The study indicated that inflammatory regions, such as those found in infants following surgery, would have a significantly different temperature distribution than the surrounding skin. The method differentiated between an inflammatory and non-inflammatory region on the abdomen

The role of the vagus nerve during fetal development and its relationship with the environment

The autonomic nervous system (ANS) regulatory capacity begins before birth as the sympathetic and parasympathetic activity contributes significantly to the fetus' development. Several studies have shown how vagus nerve is involved in many vital processes during fetal, perinatal and postnatal life: from the regulation of inflammation through the anti-inflammatory cholinergic pathway, which may affect the functioning of each organ, to the production of hormones involved in bioenergetic metabolism. In addition, the vagus nerve has been recognized as the primary afferent pathway capable of transmitting information to the brain from every organ of the body. Therefore, this hypothesis paper aims to review the development of ANS during fetal and perinatal life, focusing particularly on the vagus nerve, to identify possible "critical windows" that could impact its maturation. These "critical windows" could help clinicians know when to monitor fetuses to effectively assess the developmental status of both ANS and specifically the vagus nerve. In addition, this paper will focus on which factors (i.e. fetal characteristics and behaviors, maternal lifestyle and pathologies, placental health and dysfunction, labor, incubator conditions, and drug exposure) may have an impact on the development of the vagus during the above-mentioned "critical window" and how. This analysis could help clinicians and stakeholders define precise guidelines for improving the management of fetuses and newborns, particularly to reduce the potential adverse environmental impacts on ANS development that may lead to persistent long-term consequences. Since the development of ANS and the vagus influence have been shown to be reflected in cardiac variability, this paper will rely in particular on studies using fetal heart rate variability (fHRV) to monitor the continued growth and health of both animal and human fetuses.Comment: Word count: 16,009 Tables: 1 Figures:

Non-invasive optical monitoring of free and bound oxygen in humans

Background: Possibilities of detecting oxygen - both in its free form, as gas in the lungs, and in its bound form, as oxygenated hemoglobin - have been explored in this thesis. Perfusion and oxygenation of vital organs (e.g., heart, brain and kidneys) may be severely compromised in critical illness or major trauma, which is why blood is rapidly diverted to those organs to improve chances of survival. Blood vessels in less important organs (e.g., skin, skeletal muscles and intestines) are constricted, leading to reduced regional perfusion and oxygenation in these organs. Non-invasive measurements of changes in tissue perfusion and oxygenation, in e.g., the forearm, might give an early indication of clinical deterioration. Preterm infants are very vulnerable patients. Their organs, in particular the lungs, are not fully developed, and the respiratory distress syndrome (RDS) frequently occurs. The intestines may be affected by necrotizing enterocolitis (NEC). Complementary diagnostic and surveillance methods of RDS and NEC are desirable. Aims: The overall aim of this thesis, which includes Studies I-IV, was to develop and evaluate non-invasive optical techniques, based on light at different wavelengths, to complement future bedside surveillance in critically illness or severe injury, for adults as well as for infants. Methods: Changes in tissue oxygenation by near-infrared spectroscopy (I-II), blood perfusion by laser Doppler imaging (I) and blood volume by tissue viability imaging (I) in skeletal muscle and skin were studied, and continuous-wave and timeresolved near-infrared spectroscopy were compared (II) in healthy volunteers subjected to various defined regional physiological perturbations. For the first time, gas in scattering media absorption spectroscopy (GASMAS) was used to detect alveolar water vapor (III-IV) and oxygen gas (IV), as well as intestinal water vapor (III) in newborn infants. Main results: Near-infrared spectroscopy, laser Doppler imaging and tissue viability imaging provided valuable information on physiological changes in the microcirculation (I). Continuous-wave and time-resolved near-infrared spectroscopy techniques were both able to determine changes in tissue oxygenation, but the time-resolved technique provided more realistic values with smaller inter-individual differences (II). Alveolar (III-IV) and intestinal signals of water vapor (III), were readily detected, together with alveolar signals of oxygen gas (IV), non-invasively in newborn infants. Conclusions: Optical techniques, being non-invasive and providing data in real-time, are attractive as potential tools for surveillance in critical illness or severe injury, in particular concerning the oxygenation. As an overall conclusion, we believe, that fully developed time-resolved near-infrared techniques have the potential to become an additional monitoring method of choice for surveillance of critically ill or severely injured patients. Likewise, GASMAS has great potential for future monitoring of critically ill preterm or full-term infants, and might, ultimately, reduce the current use of X-ray imaging in these most vulnerable patients

Early newborn care practices and the development and functionality of the human microbiome

Background: The protease family, a group of enzymes produced by the host and bacterial species, play important roles in maintaining the homeostasis of the intestinal barrier. The concentrations of major gastrointestinal proteases including; pepsin, trypsin, and chymotrypsin, have been measured in preterm neonates. However, their longitudinal development is not well described. This thesis aims to investigate the dynamics of proteases, relate activity to disease and bacterial colonisation and measure their impact in vitro in a neonatal cohort. Methods: Daily faecal and ileostomy samples were collected from birth until discharge or death in 66 preterm neonates born before 32 weeks’ gestation. Substrate and inhibitor-based assays were applied to profile total protease activity (ng/µL trypsin equivalent (TE)) in 20 control neonates, three surgically confirmed necrotising enterocolitis (NEC) cases, one spontaneous intestinal perforation (SIP) case, one intestinal atresia case, and three culture confirmed septicaemia cases. Postnatal colonisation of the intestinal tract was followed in 15 neonates by metataxonomic analysis. The proteolytic impact on the intestinal barrier was assessed in a Caco-2 cell model. Results: Control, NEC/SIP and septicaemia neonates were characterised by patterns of high and low proteolytic activities. Activity increased with postmenstrual age only in control neonates (p<0.05). Inhibitor analysis revealed faecal and ileostomy samples were characterised by serine and cysteine proteases. Colonisation was irregular and dominated by genera that were not influenced by postnatal age, mode of delivery or feeding regimen. Correlation analysis revealed positive associations between Clostridium sensu stricto and Corynebacterium genera and faecal and ileostomy proteolytic activity (p <0.05). Caco-2 cell exposure to samples with low protease activity (< 250 ng/µL TE) led to a greater decrease in transepithelial electrical resistance. Conclusions: Having established that proteases are present and active during the early neonatal period; this thesis provides the scope to continue investigating their associations with bacteria and their roles in neonatal diseases.Open Acces

Gut bacterial activity in a cohort of preterm infants in health and disease

Introduction: Randomised controlled trials administering probiotic supplements to preterm infants to prevent sepsis and necrotising enterocolitis are already underway, despite the lack of a robust evidence base of normative values for gut microbiota, bacterial metabolites, and markers of inflammation and immunity. There are increasing calls for observational studies to establish baseline data in these infants. Most of these studies to date have involved the measurement of these analytes individually. In the studies presented in this thesis, we measured a range of stool markers collectively in a cohort of preterm infants in health and disease. Design: 56 infants at <32 week gestation and less than 1500g birth weight were sequentially recruited from all three Glasgow Neonatal Units within week one of life after commencement of enteral feeds. Anthropometric, dietary and treatment data were collected. Stool samples were taken once weekly for the first four weeks, testing: short chain fatty acids; calprotectin, secretory immunoglobulin A; and microbial diversity by temporal temperature gel electrophoresis. Results: Out of 61 live births meeting the study criteria, 56 infants were enrolled in the study, 62.5% of whom were female. 19.6% were between 24-26 weeks gestation, 28% were 26-28 weeks, 30% were 28-30 weeks, and 21% were 30-32 weeks. 5.3% were between 490-600g in birth weight, 17.8% were 600-800g, 21.4% were 801-1000g, 39.2% 1001-1250g, and 16% were between 1251-1500g. Feed regimen was heterogeneous, comprising 5 combinations of maternal, donor and formula milks. The highest social deprivation level as measured by the Carlisle ‘Depcat’ scoring system of level 7 was significantly higher in the study group than Glasgow or Scotland-wide averages. Sepsis rates were low, with a group median of only 1 per infant. Overall mortality: 7%. 32 with any NEC (56%), 20 with Bells’ ≥2a NEC. 8 (14%) with surgically treated NEC, 5 (8%) underwent ileostomy. SCFAs: (n=56) there were no correlations between gestation, weekly totals, feed type, or NEC and SCFA concentration. Acetate and lactate dominated each sample. Few significant changes were noted with respect to NEC, and these were in the less dominant SCFAs: stage 2a NEC showed higher concentrations of propionate in week 4 than week 3, and lower valerate in week 4 than 2. Stage 3b levels of isobutyrate and heptanoate were significantly lower in week 4 than 3. FC: (n=56) there were no significant differences in FC levels between each week in infants with or without NEC, although the former illustrated a trend to lower levels by week 4. There were no significant differences in NEC before and after clinical signs were apparent, or in those before NEC and after stoma formation for stage 3b NEC. However, significantly lower FC levels were noted in stage 3b NEC requiring ileostomy compared to the immediate pre-operative sample. SIgA: (n=34) Levels rose significantly week on week, and were considerably higher in weeks three and four than week one. There were no significant differences in stool SIgA concentration between infants with and without NEC. A significant increase in mean stool SIgA concentration appeared from week 2 to week 3 in NEC infants, and from week 1 to week 2 for those without. For all breastfed preterm neonates (n=6), the level of milk SIgA was significant higher on week 1 (colostrum) than week 2 and week 3. TTGE: (n=22) There was large variability between number (1-17) and species diversity (25-36 different species). Bacterial composition varied largely between the 2 sample points. No difference in species richness or similarity within the 2 feeding groups was observed. 4 bands were identified in >50% of infants. Intra-individual similarity varied greatly and ranged from a similarity index (Cs) of 0% to 66.8%. There was no statistical difference between the similarity indices of the feeding groups or between those with and without NEC. There were no significant correlations between any of the analytes. Conclusions: Only extreme prematurity and extremely low birth weight were associated with NEC, which was at a strikingly high incidence. A limitation was therefore the unexpected onset of severe NEC resulting in prolonged paralytic ileus with low stool production. No correlations were found between analytes, indicating that each set of stool investigations may signify independent physiological, biochemical and immunological gut processes. Despite the severity of NEC, the levels of each analyte were remarkably consistent. High levels of deprivation within the study population may provide the constellation for an as of yet undefined genetic and epigenetic predisposition to NEC in this cohort, similar to that of other illnesses endemic to different geographical areas – notably Multiple Sclerosis in the North East of Scotland – and both follow up of these infants into childhood as well as further analysis of future inborn infants with NEC is planned

Investigating the immune system of extremely preterm infants and the effect of diet

M. D. Thesis.Extremely preterm infants are susceptible to life-threatening diseases, specifically late onset sepsis (LOS) and necrotising enterocolitis (NEC). Both these diseases are associated with changes in the gut microbiota and an immature immune response. Mother’s own milk (MOM) has been shown to reduce the incidence of both NEC and LOS. When MOM is not available, the alternatives are donor human milk (DHM) or cow’s milk formula (CMF). Clinical trials have shown an inconsistent effect on rates of NEC or LOS when DHM is used instead of CMF to make up any shortfall of MOM, although the use of DHM or CMF as sole diet tends to favour DHM. Inconsistencies or lack of effect could be due to differences in the concentration of bioactive components of DHM compared to MOM, as DHM is usually from donors who are longer post-partum, and is usually pasteurised and frozen. The diet of preterm infants affects both their gut microbiota and gut mucosal T cells, which may be instrumental to any impact on LOS and NEC. This study aimed to identify differences in gut microbial or T cell composition if infants were fed an exclusively human milk (MOM+/-DHM) diet (Intervention) compared to a diet containing bovine products (MOM+/-CMF) (Control). The hypothesis was that an exclusively human milk diet would be associated with changes in microbial diversity, abundance of Bifidobacteria, Regulatory T cells, Mucosa-associated invariant T cells and invariant natural killer T cells. Infants of less than 30 weeks gestational age (GA) were recruited to a randomised controlled trial comparing the two diets until 34 weeks GA. Stool samples were taken throughout the trial period, which were analysed using 16S rRNA sequencing at 5 time-points, and blood samples taken at 2 time-points were analysed using mass cytometry. This report provides data from a pilot study of 59 infants. Infants in the intervention group paradoxically received less MOM overall and had decreased rate of growth (weight). There was a significant difference in unweighted microbial beta-diversity at 34 weeks GA and a significantly increased abundance of lactobacillus at 34 weeks GA in the control group. There was no difference in T cell populations between the trial populations, however clear differences were noted when compared to adult control samples. In conclusion, an exclusively human milk diet did not result in measurable changes in gut bacterial community structure or changes in T cell immunophenotype when compared to a diet containing bovine products. However, the routine use of supplemental probiotics containing Bifidobacteria and Lactobacillus in this study population may mask important effect

Investigating the longitudinal development of the intestinal microbiome in preterm infants

Background: As the spectrum of morbidity and mortality in preterm infants shifts to conditions such as late-onset sepsis and necrotising enterocolitis, the importance of understanding the role that intestinal dysbiosis plays in the development of these conditions has become vital. Aims: This study will examine the longitudinal development of the intestinal microbiome in preterm infants, and assess factors which may contribute to the development of dysbiosis. Methodology: Subjects were approached for recruitment if born at less than 32 completed weeks’ gestation. Stool samples were regularly obtained from these infants, through to term, and correlated with prospectively collected clinical data. Bacterial DNA was extracted from these samples, and community profiling performed on the V4 region of the 16S rRNA gene using Illumina MiSeq. Dynamic biometrics of longitudinal microbiome development were derived, to describe the development of the microbiome in periods of clinical stability, and under the action of interventions which may act as microbiome modulators. Results: 71 subjects (mean gestational age 27.9 weeks; mean birthweight 990g) were studied. In stable subjects, consistent trends in biometric and taxonomic development could be identified once confounders were excluded. The use of antibiotics was seen to have both an acute and longer-term impact upon the microbiome development, with suppression of diversity progression and retention of elevated Enterobacteriaceae levels. Noninvasive respiratory support also inhibited diversity progression. Microbiome development was not affected by the introduction of cow’s milk-containing feeds, nor by blood transfusions. Unwell infants receiving frequent interventions showed increased microbiome instability, and suppression of the presence of commensal organisms. Conclusion: In the absence of exogenous modulators of microbiome development, consistent trends in apparent bacterial colonisation can be seen. Common clinical interventions can affect the stability and persistence of these trends. The occurrence of such events must be considered in the design and interpretation of data in preterm intestinal microbiome studies

Psychological Case Record

DIAGNOSTIC CLARIFICATION: Master V was noticed to have persistent, intractable hiccough for the past one year. It was present throughout the day and was absent during sleep. He could voluntarily control the hiccough for only a while by holding his breath. The hiccough was exacerbated by anxiety-provoking situations. There was no history suggestive of organic pathology for hiccough. Several physicians were consulted for the same but without any improvement. For the past six months, Master V was observed to be preoccupied. He was found to be in tearful most often. He expressed that he felt sad but could not explain the reason. He was found to be disinterested in mingling with his peers. He was occasionally expressing feelings of helplessness. He also expressed guilt feelings. He reported that he had poor appetite. There was no change in his sleep pattern. He was able to maintain his basic activities of daily living. There was no history of expressing hopelessness or worthlessness or suicidal ideas. There were no melancholic features. There was no history suggestive of hypomania or mania. There was no history of psychosis. There was no history suggestive of an organic involvement. CONCLUSION: The diagnosis of depression was confirmed. He was started on antidepressant. A diagnosis of Somatoform autonomic dysfunction (upper gastrointestinal) was also made. Principles of cutting down secondary gains and differential reinforcement were discussed. He was found to be anxious, timid and less assertive. He had low average intelligence. There was pressure to excel in academics. Moreover there was comparison to a well-performing elder sister. This conflict resulted in strong resentment towards his sister. There was also a conflict due to low socioeconomic status. The boy was deeply distressed regarding the marital problems between parents and the substance use pattern of his father. The implication of low intelligence on academic performance was discussed. A step down in curriculam with reduced pressure in academics was encouraged. Coping skill training, assertiveness training, academic skill building, role plays, group activities, and relaxation technique training were practiced. The need to avoid direct confrontation between parents in presence of children was stressed. The option of father getting treated for alcohol consumption in adult psychiatry too was discussed. At the time of discharge, Master V was euthymic. There was marked improvement in hiccough. PERSONALITY ASSESSMENT: The complaints started while he was doing his intermediate. He started experiencing repeatitive and recurrent thoughts of dead body whenever he came across his close relatives, of throwing chappal at idol while worshipping and of faecal matter while taking food. He acknowledged those thoughts as his own. He also considered those thoughts were absurd and senseless. But the thoughts were occurring without his will. They were so intrusive that his attempts to resist them most often failed. These thoughts were reportedly occurring in clear consciousness and, was dominating and persisting without any cause. Hence he was in deep distress. He could manage his studies and passed intermediate. While doing BCom the intensity and severity of unusual thoughts increased. Moreover, he started having a repetitive and recurrent urge to keep things in order, check lock and zip. This also he considered as own action not being imposed by others, as absurd and senseless, but intrusive occurring in clear consciousness. These were dominating and persisting without any cause. There was release of tension after the act. The thoughts and acts were so intense that he sometimes used to feel death wish. His sleep too was disturbed. There were no active suicidal plans or suicidal attempts so far. There was no pervasive sad mood or lack of interest in pleasurable activities or easy fatiguability. There was no pervasive feeling of worthlessness or hopelessness or helplessness. There was no loss of libido or loss of weight. There was no early morning awakening. The thoughts and acts were so impairing that he stopped his studies. He could not make steady progress in business so that he was expelled by his business partners. Though his personal care was reportedly adequate, there was severe interference due to the complaints. There was impairment in instrumental activities of daily living. There was no history suggestive of first rank symptoms. There was no history of expressing false belief with conviction. There was no history of any abnormal perception. There was no history of mania or hypomania. There was no history of phobia or panic attacks. There was no history suggestive of organicity or seizures. CONCLUSION: The defense mechanisms were mostly mature and neurotic. There were major conflicts in areas of sexuality and autonomy. Obsessive compulsive personality with ego strength was confirmed. He was found to be vulnerable to social rejection. There was also tendency to loss self-sufficiency. Both finally may culminate in somatisation with secondary gain. There were significant conflicts in family relations especially with parents. Hatred towards mother has to be explored. Conflicts in sexuality warrants further probing. It was decided to give an adequate trial of Fluoxetine and augment it with Clonazepam. Non-pharmacologically, cognitive behaviour therapy too was started. It primarily involved exposure-response prevention strategy, where he was repeatedly exposed himself to provocative stimuli and refrained from compulsions. For this, a complete list of obsessions, compulsions, and things that he avoided was first made. This list was then arranged in a hierarchy from least anxiety-provoking to most anxiety-provoking. He then started with a moderately anxiety-provoking stimulus and repeatedly exposed himself to it until the situation produces minimal anxiety (i.e., habituation). The next (more anxiety-provoking) stimulus in the hierarchy was then tackled. This was combined with cognitive therapy, in which faulty beliefs were challenged to help reduce the feeling of impending catastrophe. Social skills training with focus on helping him to deal with heavy responsibilities and stress was also undertaken. Specific techniques as instruction, feedback, and reinforcement of positive interactions were used. DIAGNOSTIC CLARIFICATION: From early childhood onwards, Mr SKA was reported to be adamant. He had poor frustration tolerance that even for trivial incidents at school or at home he will be angry and sometimes agitated. But significant changes were noticed since he was studying in 12th standard. Then he was found preoccupied with his physical appearance. He started complaining that there was more hair growth in him. He expressed concern that he was losing vitamins due to this. Hence he used to apply costly cosmetics, for which he always quarreled with his father. Once he found that cosmetics were not reducing his hair growth he started demanding consultations at various cosmetologists. He was also concerned about asymmetry of his jaw bone. Since there was no improvement with expert consultation he started demanding LASER therapy for the same. Almost during the same period, he used to get angry even for other reasons like not serving him tea on time. It was also reported that he would not persist with a task that yielded no immediate reward. He insisted on that he would do things on his own way and would not agree to others’ suggestion. At the same time he will deeply be moved by criticism. He tends to blame others when criticised. He used to blame parents for all his failures. He was always found complaining to others that he was not brought up well; he was not guided properly by parents; he was not made to excel in his academics. He used to be abusive and assaultive towards parents. He was also found blaming his friends for inappropriate behaviour toward him. He also pointed fingers at school authorities for lack of infrastructure at school, one of the reasons he considered for his poor scholastic performance. His sleep too was disturbed. There was difficulty in sleep initiation. He used to get up late in the morning. His personal care was reportedly adequate, but there was no routine. Since all these complaints started simultaneously while studying in 12th standard, he did not complete the academic year. Then he worked in a stationary shop. Gradually he stopped going for work. Thereafter he spent all his time at house mostly sleeping or relaxing. There was gross impairment of instrumental activities of daily living. There was no history suggestive of first rank symptoms. There was no history of expressing false belief with conviction. There was no history of any abnormal perception. There was no history of depressive syndrome or mania or hypomania. There was no history of phobia or panic attacks. There was no history suggestive of organicity or seizures. His index visit to us was on 25/4/2007 with multiple somatic symptoms, anxiety and agitation. Initially, possibilities of anxious personality disorder and somatoform disorder were considered. Later on, he was described to have repeated behaviour of checking and washing. Hence, diagnoses of Obsessive compulsive disorder and Somatisation disorder were made. CONCLUSION: The tests revealed his personality traits viz. avoidant, emotional dysregulation, sensitivity to stressors, and obsessions. He was prone to exhibit maladaptive behaviour under stressful situation. His disregard to social norms was also evident. The difficulty in decision-making and problem-solving justify his dissatisfaction with life. The environment was perceived threatening and insecure. Poor interpersonal relations can be due to both the cause and the effect of his psychopathology. The test results also point towards his significant difficulty in reality testing indicating a psychotic psychopathology. The use of narcissistic and neurotic defenses further strengthens the possibility of psychosis and personality disorder respectively. A current working diagnosis of mixed personality disorder with high index of suspicion of prodrome of schizophrenia was concluded. NEUROPSYCHOLOGICAL ASSESSMENT: The episodes started when Mr ARS was twelve years of age. Mr ARS’s mother first noticed that, Mr ARS had a vacant stare while having his lunch. She also observed that he was spreading the food in plate with his right hand. Suddenly she called him but he was found unresponsive. After twenty to thirty seconds, he became responsive. There was no major confused state after the episode. When his mother tried to clarify what was happening, he could not recollect whether any such episode has happened. There was no involvement of any other limbs. There was no lip smacking or any other complex motor activity. There was no aura. There were no tonic-clonic movements or incontinence or frothing or loss of consciousness with postural fall suggestive of generalised tonic-clonic seizure. There was no fever prior to the episode. Afterwards, he was normal to his studies with no residual effect. Hence he was not consulted then. Four months later he had second episode of similar semiology. Then he was taken to a local physician who started him on Carbamazepine. While on medication, he again had similar episode four months later. Then he was consulted by a Neurologist. After imaging, the dose of Carbamazepine was titrated. But he continued to experience at least one episode every four months mostly while having food. The episodes were not interfering with his daily activities and the episodes were of short duration that they did not seek any change in medication. He was compliant with medication but no drug levels were done. From the age of twenty nine, he started experiencing aura – an abnormal sensation in abdomen that ascends upto his neck and a sense of arrested speech. This will last a few seconds. It will be followed by the episode as described before. It was reported that not all aura was followed by seizure. During the same period, while driving a motorbike he probably had an episode; he fell down; he sustained left clavicular fracture. A few other episodes occurred at work place. While he was soldering he developed a seizure episode. Then he unknowingly moved the soldering iron to his face and burned his face. Similarly he burned his hand once. Since the episodes started affecting his daily activities some of which were life threatening, he consulted another Neurologist. He was started on Phenytoin in addition to Carbamazepine. The dose was titrated. There was no significant change in frequency or severity of episodes. In view of poor response to two antiepileptic medications, Sodium valproate was added as third antiepileptic. Even then he continued to have seizure in the same frequency. Hence he was brought to CMC for expert opinion. Drug levels were found to be within normal range indication good drug compliance. In view of poor control of seizure with three antiepileptics with good compliance, option of surgery was discussed. Meantime it was decided to try fourth antipepileptic Clobazam and, to taper off Carbamazepine and Sodium valproate. But he continued to develop seizure. Moreover, he could not tolerate the dose of Phenytoin that was prescribed. He had severe side effects and hence he stopped the medicine. There was no history of apathy or emotional lability or sexual disinhibition. There was no history of forgetfulness or difficulty in speech. There was no history of apraxia or difficulty in calculation. There was no history suggestive of psychosis or syndromal depression or mania. There was no history of deviant personality traits or obsessions or compulsions or phobia or panic attacks. There was no history of head injury. His biological functions were reportedly normal. He still continued to maintain his basic and instrumental activities of daily living independently. INTELLIGENCE QUOTIENT ASSESSMENT: Master T A was brought with history of disobedience, abusing parents, demanding immediate ratification of his demands, behaving opposite to what elders ask him to and deliberately annoying others, since he joined 5th standard. Simultaneously there was gradual deterioration in his scholastic performance. He was reportedly inattentive in class and was disturbing his classmates during sessions. Back at home, he was spending little time for his studies, often making excuses during study time. He could independently carry out age-appropriate basic and instrumental activities of daily living. There was no history suggestive of attention deficit hyperactivity disorder or conduct disorder. There was no history suggestive of psychotic syndrome, mood syndrome, obsessive-compulsive disorder, anxiety disorder or phobia. There was no history suggestive of organicity or substance us

The nature of gut microbiota in early life:origin and impact of pioneer species

During early childhood, a complex ecosystem of thousands of species of microorganisms develops in our gastrointestinal tract. Disruptions in this development can have lifelong consequences and possibly increase the risk of diseases such as allergies and asthma. In this thesis, the influence of environmental and host factors on the early development of the microbiota was investigated. In addition, the microbiota composition of children in two birth cohorts in relation to the development of allergies and asthma was studied. The oral administration of specific beneficial bacteria, called probiotics, may be a way to specifically manipulate the gut microbiota to achieve health benefits. The last research studied how administering different types of probiotics, consisting of lactobacilli and bifid bacteria, affects the microbiota and health of premature infants. This thesis highlights that early childhood is a critical period in which targeted manipulation of the gut microbiota is possible in order to promote a healthy future and prevent the development of allergies and asthma

Mapping the gut microbiome to preterm neonatal outcomes

The development of the gut microbiome in preterm infants can have a substantial impact on health, such as the development of the common preterm disease Necrotizing Enterocolitis (NEC). This thesis aimed to identify further areas in which the gut microbiome could be contributing to the development of disease in preterm infants. Experimental methodology included, 16S rRNA gene metataxonomics, to map the preterm gut microbiome. In addition, protease activity and inhibition assays were implemented to assess total faecal protease activity and identify families of proteases present. Moreover, ELISAs were used to investigate inflammatory content of preterm infant stool. Finally, data from a project, by Dr David Gallacher, into the lung microbiome of preterm infants was analysed with the data from this project to establish links between the development of the gut and lung microbiomes of preterm infants. The results of this thesis found that the preterm gut microbiome shifts from a Firmicute dominated community to a Proteobacteria one, during the first 30 days of life. In addition, associations between gender, mode of delivery, antibiotics and sampling site were found. Secondly, no significant changes in protease activity were found over time, however, protease activity during the first 30 days of life varied between individuals. Thirdly, no inflammatory response was detected in the stool of preterm infants. Finally,no significant associations between the bacterial communities of the gut and the lung of preterm infants. In conclusion, novel findings of this thesis have shown that gender, antibiotics and sampling site have a significant effect of the development of the gut microbiome during the first 30 days of life. Moreover, protease and inflammatory activity of preterm infant stool was not significant. Lastly, development of the gut and lung microbiomes of preterm ventilated infants progress along very different courses