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Indian Pediatr 2015;52: 1000
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Gaurav Gupta
Email:
[email protected]
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Bubble CPAP versus standard oxygen therapies for severe
pneumonia (Lancet. 2015;386:1057-65)
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In developing countries, mortality in children with very severe
pneumonia is high, even with the provision of appropriate antibiotics,
standard oxygen therapy and other supportive care. The authors assessed
whether oxygen therapy delivered by bubble continuous positive airway
pressure (CPAP) improved outcomes compared with standard low-flow and
high-flow oxygen therapies. In this open-label randomized controlled
trial from Bangladesh, authors randomly assigned children younger than 5
years with severe pneumonia and hypoxemia to receive oxygen therapy by
either bubble CPAP (5 L/min starting at a CPAP level of 5 cm H2O),
standard low-flow nasal cannula (2 L/min), or high-flow nasal cannula (2
L/kg/min up to the maximum of 12 L/min). The primary outcome was
treatment failure (i.e., clinical failure, intubation and
mechanical ventilation, death, or termination of hospital stay against
medical advice) after more than 1 h of treatment. The authors conducted
two interim analyses and stopped the trial after the second interim on
directions of their data safety and monitoring board. Before trial could
be stopped, 225 eligible children were recruited; 79 (35%) to receive
oxygen therapy by bubble CPAP, 67 (30%) to low-flow oxygen therapy, and
79 (35%) to high-flow oxygen therapy. Treatment failed for 31 (14%)
children, of whom 5 (6%) had received bubble CPAP, 16 (24%) had received
low-flow oxygen therapy, and 10 (13%) had received high-flow oxygen
therapy. Significantly fewer children in the bubble CPAP group (and high
flow oxygen group) had treatment failure than in the low-flow oxygen
therapy group. Twenty-three (10%) children died; 3 (4%) in the bubble
CPAP group, 10 (15%) in the low-flow oxygen therapy group and 10 (13%)
in the high-flow oxygen therapy group. Children who received oxygen by
bubble CPAP had significantly lower rates of death than the children who
received oxygen by low-flow oxygen therapy (P=0·022). The authors
suggest that use of bubble CPAP oxygen therapy could have a large effect
in hospitals in developing countries where the only respiratory support
for severe childhood pneumonia and hypoxemia is low-flow oxygen therapy.
The trial was stopped early because of higher mortality in the low-flow
oxygen group than in the bubble CPAP group, and the authors acknowledge
that the early cessation of the trial reduces the certainty of the
findings.
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New polio vaccination schedule –Does it work?
(Lancet. 2015 Sep 17. doi: 10.1016/S0140-6736(15)00237-8)
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Polio eradication needs a new routine immunization
schedule – three or four doses of bivalent type 1 and type 3 oral
poliovirus vaccine (bOPV) and one dose of inactivated poliovirus vaccine
(IPV), but no immunogenicity data are available for this schedule. The
authors aimed to assess immunogenicity of this vaccine schedule. They
conducted this open-label, randomized controlled trial in four centers
in India. Healthy newborn babies were randomly allocated to one of five
groups: trivalent OPV (tOPV); tOPV plus IPV; bOPV; bOPV plus IPV; or
bOPV plus two doses of IPV (2IPV). OPV was administered at birth, 6
weeks, 10 weeks, and 14 weeks; IPV was administered intramuscularly at
14 weeks. The primary study objective was to investigate immunogenicity
of the new vaccine schedule, assessed by seroconversion against
poliovirus types 1, 2, and 3 between birth and 18 weeks. Neutralization
assays tested cord blood and sera collected at 14 weeks, 18 weeks, 19
weeks, and 22 weeks by investigators masked to group allocation. Of 900
newborn babies enrolled, 782 (87%) completed the protocol requirements.
Between birth and age 18 weeks, seroconversion against poliovirus type 1
in the tOPV group occurred in 98-99% in all groups. Seroconversion
against poliovirus type 2 occurred in 157 (96·3%) of 163 in the tOPV
group, 153 (100%) of 153 in the tOPV plus IPV group, 29 (18.7%) of 155
in the bOPV group, 107 (68·6%) of 156 in the bOPV plus IPV group, and in
121 (78·1%) of 155 in the bOPV plus 2IPV group. Seroconversion against
poliovirus type 3 was achieved in 147 (90·2%) of 163 in the tOPV group,
152 (99·3%) of 153 in the bOPV plus IPV group, 151 (97·4%) of 155 in the
bOPV group, 155 (99·4%) of 156 in the bOPV plus IPV group, and 153
(98·7%) of 155 in the bOPV plus 2IPV group. Superiority was achieved for
vaccine regimens including IPV against poliovirus type 3 compared with
those not including IPV (tOPV plus IPV vs tOPV alone; and bOPV
plus IPV vs bOPV alone).
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Do early life infections increase the risk of celiac disease?
(Am J Gastroenterol. 2015;110:1475-84)
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Studies on early life infections and risk of later celiac disease are
inconsistent but have mostly been limited to retrospective designs,
inpatient data, or insufficient statistical power. Using prospective
population-based data, the authors aimed to test whether early life
infections are associated with increased risk of later celiac disease.
This study, based on the Norwegian Mother and Child Cohort Study,
includes prospective, repeated assessments of parent-reported infectious
disease data up to 18 months of age for 72,921 children born between
2000 and 2009. Celiac disease was identified through parental
questionnaires and the Norwegian Patient Registry. During a median
follow-up period of 8.5 years (range, 4.5–14.5), 581 children (0.8%)
were diagnosed with celiac disease. Children with e"10 infections (e"fourth
quartile) up to age 18 months had a significantly higher risk of later
celiac disease, as compared with children with £4 infections (£first
quartile; aOR=1.32; 95% CI 1.06,1.65; per increase in infectious
episodes, aOR=1.03; 95% CI 1.02,1.05). The aORs per increase in specific
types of infections were as follows: upper respiratory tract infections:
1.03; lower respiratory tract infections: 1.12; and gastroenteritis:
1.05. This study suggests that early life infections may have a role in
development of celiac disease. However, non-causal explanations for this
association due to surveillance bias and reverse causation cannot be
excluded.
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