Whole Body Cooling (WBC) for newborn infants with perinatal asphyxia: A feasibility trial

INTRODUCTION: Neonatal mortality accounts for two-thirds of the infant mortality rate in India and other developing countries. It is estimated that over 1 million newborn infants die during the first four weeks of life. The current neonatal mortality rate in India is 39 per 1000 live births.1 Asphyxia was the single most important cause of still-births, accounting for 45.1% of all intrauterine deaths and the primary cause for neonatal mortality, accounting for 28.8% of all the deaths.2 Morbidity associated with perinatal asphyxia includes cerebral palsy, learning disabilities, visual and hearing impairments, behavioural abnormalities and residual motor or cognitive disabilities. These have a considerable effect on the surviving babies, their families and on society. The etiology of perinatal Hypoxic Ischemic Encephalopathy (HIE) includes those conditions that can affect the cerebral blood flow in the fetus and newborn compromising the supply of oxygen to the brain. They may develop antepartum (20%), intrapartum (30%), intrapartum and antepartum (35%) or postpartum (10%). HIE that develops in the setting of perinatal asphyxia is part of a multiorgan system disease. After an asphyxial event, there may be an opportunity to intervene to minimize brain damage. The first phase of brain damage, early cell death, results from the primary exhaustion of cellular energy stores. Early cell death can occur within minutes. Damage to the brain is limited at this stage by immediate resuscitation to restore oxygen supply and blood circulation. A secondary phase of neuronal injury occurs some times after the initial insult. There are several mechanisms involved in this process. Treatment during the post resuscitation phase aim to block these processes thereby limiting secondary cell damage and minimizing the extent of potential brain damage. Neuroprotection was achieved in animal models of brain ischemia by reduction in brain temperature by 2°C to 5°C.6-11 Randomized control trials done in the developed countries using expensive equipment was shown to reduce mortality and morbidity among newborn survivors of perinatal asphyxia.12-17 The present trial was conducted to evaluate whether whole-body cooling could be achieved in a lowresource setting using simple available cooling materials. AIM AND OBJECTIVES: Aim and objectives: To study the feasibility of whole body cooling for newborn infants with perinatal asphyxia in a low resource setting. Primary objective: Achievement of target temperature within 1 hour of initiation of treatment and within 6 hours of birth and maintaining the target temperature for 72 hours. Secondary objectives: Monitoring adverse events and possible complications that could occur secondary to whole body cooling. 1. Cardiac arrhythmia, 2. Persistent hypoxemia, 3. Hypotension despite full inotropic support, 4. Skin changes, 5. Thrombocytopenia, 6. Life threatening coagulopathy, 7. Arterial thrombosis, 8. Hepatic and renal failure, 9. Electrolyte disturbances, 10. Death. METHODOLOGY: Babies who were recruited into the trial included inborn (born at the Christian Medical College and Hospital) and outborn (born in a place other than the Christian Medical College and Hospital) admitted into the neonatal unit of the hospital. Inclusion and exclusion criteria for Inborn babies. Inclusion criteria: 1. Gestational age >35 wks, 2. pH 12 in umbilical cord arterial blood sample or postnatal ABG within firs hour of life AND, 3. Any two of the following, 4. Apgar score < 5 at 5 minutes, 5. Ventilation initiated at birth and continued for at least 10 minutes, 6. History of acute perinatal event (any one) • Intrapartum fetal distress, • Cord prolapse, • Placental abruption, • Maternal respiratory arrest, • Uterine rupture / dehiscence. Exclusion criteria: 1. Inability to start cooling the baby by 5.0 hours of age, 2. Small for gestational age babies (less than 10th centile for age), 3. Chromosomal abnormality, 4.Major congenital anomaly, 5. Refusal of consent for study participation. Inclusion and Exclusion criteria for Outborn babies: Inclusion criteria (all 3): • Gestational age >35 wks. • Babies who did not cry immediately after birth with any or all of the following features: 1. Not breathing normally at five minutes of birth, 2. Given assistance for breathing during or soon after birth, 3. Limp or flaccid since birth, 4. Not sucking well at the breast since birth without any oro-facial abnormality if documented by a pediatrician, 5. Apgar score of 5 or less at 5 minutes, • Evidence of encephalopathy Exclusion criteria: 1. Inability to start cooling the baby by 5.0 hours of age, 2. Small for gestational age babies (less than 10th centile for age), 3. Chromosomal abnormality, 4. Major congenital anomaly, 5. Refusal of consent for study participation. CONCLUSIONS: The conclusions of this feasibility trial are: 1. In a low resource setting, it is feasible to • Obtain an informed consent and start the procedure within the acceptable time-frame of 6 hours following birth. • Achieve a target rectal temperature within 6 hours of birth and 90 minutes of commencement of whole body cooling. • Maintain the target rectal temperature for 72 hours. 2. Low-cost, easily available and reusable materials like cloth covered ice-gel packs are sufficient for achieving and maintaining the target rectal temperature. 3. Constant and careful monitoring of the skin temperature may be adequate in low resource centers. 4. There were only minimal serious adverse events during this procedure. • Newborn infants who have deranged coagulation parameters with obvious signs of bleeding should probably be excluded from the cooling process

Primary cemented bipolar hemiarthroplasty by transtrochanteric approach in unstable intertrochanteric fractures

Background: The successful treatment of unstable intertrochanteric fractures of the femur in elderly patients is a challenge. Due to complications associated with internal fixation, primary hemiarthroplasty is increasingly becoming an alternative treatment to achieve early mobilisation. A transtrochanteric approach could potentially decrease the complications associated with primary hemiarthroplasty. Aim of the study is to document the postoperative outcome and complications associated with this treatment.Methods: In this retrospective study, all elderly patients with unstable trochanteric fractures, treated by primary hemiarthroplasty through a transtrochanteric approach, in a tertiary care centre, from September 2017 to December 2019, were enrolled. Their data from hospital records were analysed and results compared to literature.Results: 48 patients underwent the procedure. Average age was 85 years. One year mortality was 31.25%. Average duration of surgery is 85 min. 58.3% were ambulant at one year. One case of dislocation secondary to surgical site infection was present.Conclusions: Primary hemiarthroplasty as a primary treatment in this group of patients enables early mobilization and prevents complications associated with prolonged immobilization. Transtrochanteric approach reduces the duration of surgery. Achieving early ambulation is the key to successful treatment

More insights into bar quenching. Multi-wavelength analysis of four barred galaxies

The underlying nature of the process of star formation quenching in the central regions of barred disc galaxies that is due to the action of stellar bar is not fully understood. We present a multi-wavelength study of four barred galaxies using the archival data from optical, ultraviolet, infrared, CO, and HI imaging data on star formation progression and stellar and gas distribution to better understand the process of bar quenching. We found that for three galaxies, the region between the nuclear or central sub-kiloparsec region and the end of the bar (bar region) is devoid of neutral and molecular hydrogen. While the detected neutral hydrogen is very negligible, we note that molecular hydrogen is present abundantly in the nuclear or central sub-kiloparsec regions of all four galaxies. The bar co-rotation radius is also devoid of recent star formation for three out of four galaxies. One galaxy shows significant molecular hydrogen along the bar, which might mean that the gas is still being funnelled to the centre by the action of the stellar bar. Significant star formation is also present along the bar co-rotation radius of this galaxy. The study presented here supports a scenario in which gas redistribution as a result of the action of stellar bar clears the bar region of fuel for further star formation and eventually leads to star formation quenching in the bar region.Comment: Accepted for publication in A&A. Continuation on the letter paper (arXiv:1812.04178) to appear in main journa

Assessment of myofascial pain syndrome among married female healthcare workers: a cross sectional comparative study in a tertiary care centre

Background: Myofascial pain syndrome (MPS) is common among females between ages 20-40 years. Psychosomatic and mechanical reasons are attributed as causative factors. Female health care workers (FHW) in hospitals with rapid patient turn over are vulnerable to develop MPS. Our aim was to ascertain the prevalence of MPS in married FHW working in various departments of the hospital and its association with poor sleep and work stress. Methods: We selected married FHWs in 20-50 years age group and divided them into two groups, medical and paramedical (those involved directly and indirectly with patient care respectively). MPS was diagnosed after detailed personal interview and clinical examination. Sleep duration was divided into less than 5 hours and more than 5hours. Presence of work-related stress and other medical parameters were also recorded. Results: A total of 150 medical and 150 paramedical FHWs were included in the study. Overall prevalence of MPS among FHWs was 42%, of which, medical group was 32% and paramedical was 52%. The paramedical group showed significantly higher prevalence of MPS (p: 0.02). Sleep was less than 5 hours in 29.3% of medical FHW and 13.3% of paramedical. This difference didn’t show any association to MPS (p=0.8). 38% FHW perceived excessive work stress, 40% were paramedical and 36% were medical. This didn’t correlate with prevalence of MPS (p=0.2) among them. Conclusions: Paramedical FHW experienced more MPS than medical and it was more of mechanical type and not due to work stress or sleep deprivation

GASP XVIII: Star formation quenching due to AGN feedback in the central region of a jellyfish galaxy

We report evidence for star formation quenching in the central 8.6 kpc region of the jellyfish galaxy JO201 which hosts an active galactic nucleus, while undergoing strong ram pressure stripping. The ultraviolet imaging data of the galaxy disk reveal a region with reduced flux around the center of the galaxy and a horse shoe shaped region with enhanced flux in the outer disk. The characterization of the ionization regions based on emission line diagnostic diagrams shows that the region of reduced flux seen in the ultraviolet is within the AGN-dominated area. The CO J$_{2-1}$ map of the galaxy disk reveals a cavity in the central region. The image of the galaxy disk at redder wavelengths (9050-9250 \overset{\lower.5em\circ}{\mathrm{A}}) reveals the presence of a stellar bar. The star formation rate map of the galaxy disk shows that the star formation suppression in the cavity occurred in the last few 10$^8$ yr. We present several lines of evidence supporting the scenario that suppression of star formation in the central region of the disk is most likely due to the feedback from the AGN. The observations reported here make JO201 a unique case of AGN feedback and environmental effects suppressing star formation in a spiral galaxy.Comment: Author's accepted manuscrip

Dissecting star-formation in the "Atoms-for-Peace" galaxy: Ultra-Violet Imaging Telescope observations of the post-merger galaxy NGC7252

The tidal tails of post-merger galaxies exhibit ongoing star formation far from their disks. The study of such systems can be useful for our understanding of gas condensation in diverse environments. The ongoing star formation in the tidal tails of post-merger galaxies can be directly studied from ultraviolet (UV) imaging observations. The post merger galaxy NGC7252 ("Atoms-for-Peace" galaxy) is observed with the Astrosat UV imaging telescope (UVIT) in broadband NUV and FUV filters to isolate the star forming regions in the tidal tails and study the spatial variation in star formation rates. Based on ultraviolet imaging observations, we discuss star formation regions of ages $<$ 200 Myrs in the tidal tails. We measure star formation rates in these regions and in the main body of the galaxy. The integrated star formation rate of NGC7252 (i.e., that in the galaxy and tidal tails combined) without correcting for extinction is found to be 0.81 $\pm$ 0.01 M$_{\odot}$/yr. We show that the integrated star formation rate can change by an order of magnitude if the extinction correction used in star formation rates derived from other proxies are taken into consideration. The star formation rates in the associated tidal dwarf galaxies (NGC7252E, SFR=0.02 M$_{\odot}$/yr and NGC7252NW, SFR=0.03 M$_{\odot}$/yr) are typical of dwarf galaxies in the local Universe. The spatial resolution of the UV images reveals a gradient in star formation within the tidal dwarf galaxy. The star formation rates show a dependence on the distance from the centre of the galaxy. This can be due to the different initial conditions responsible for the triggering of star formation in the gas reservoir that was expelled during the recent merger in NGC7252.Comment: Accepted for publication in Astronomy & Astrophysic

Ultra-Violet Imaging Telescope Observations of the Star-Forming Ring in NGC7252: Evidence of Possible AGN Feedback Suppressing Central Star Formation

Some post-merger galaxies are known to undergo a starburst phase that quickly depletes the gas reservoir and turns it into a red-sequence galaxy, though the details are still unclear. Here we explore the pattern of recent star formation in the central region of the post-merger galaxy NGC7252 using high resolution UV images from the UVIT on ASTROSAT. The UVIT images with 1.2 and 1.4 arcsec resolution in the FUV and NUV are used to construct a FUV-NUV colour map of the central region. The FUV-NUV pixel colour map for this canonical post-merger galaxy reveals a blue circumnuclear ring of diameter $\sim$ 10 " (3.2 kpc) with bluer patches located over the ring. Based on a comparison to single stellar population models, we show that the ring is comprised of stellar populations with ages $\lesssim$ 300 Myr, with embedded star-forming clumps of younger age ($\lesssim$ 150Myr). The suppressed star formation in the central region, along with the recent finding of a large amount of ionised gas, leads us to speculate that this ring may be connected to past feedback from a central super-massive black hole that has ionised the hydrogen gas in the central $\sim$ 4" $\sim$ 1.3 kpc.Comment: Accepted for publication in Astronomy & Astrophysics Letter

Parasite fate and involvement of infected cells in the induction of CD4+ and CD8+ T cell responses to Toxoplasma gondii

During infection with the intracellular parasite Toxoplasma gondii, the presentation of parasite-derived antigens to CD4+ and CD8+ T cells is essential for long-term resistance to this pathogen. Fundamental questions remain regarding the roles of phagocytosis and active invasion in the events that lead to the processing and presentation of parasite antigens. To understand the most proximal events in this process, an attenuated non-replicating strain of T. gondii (the cpsII strain) was combined with a cytometry-based approach to distinguish active invasion from phagocytic uptake. In vivo studies revealed that T. gondii disproportionately infected dendritic cells and macrophages, and that infected dendritic cells and macrophages displayed an activated phenotype characterized by enhanced levels of CD86 compared to cells that had phagocytosed the parasite, thus suggesting a role for these cells in priming naïve T cells. Indeed, dendritic cells were required for optimal CD4+ and CD8+ T cell responses, and the phagocytosis of heat-killed or invasion-blocked parasites was not sufficient to induce T cell responses. Rather, the selective transfer of cpsII-infected dendritic cells or macrophages (but not those that had phagocytosed the parasite) to naïve mice potently induced CD4+ and CD8+ T cell responses, and conferred protection against challenge with virulent T. gondii. Collectively, these results point toward a critical role for actively infected host cells in initiating T. gondii-specific CD4+ and CD8+ T cell responses

One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry.

BackgroundWe report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study.MethodsKERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF.ResultsMean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA2DS2-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%).ConclusionsDespite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry