Probiotics-Prime Time For Routine Use!

http://www.jpeds.com/article/S0022-3476(13)01596-5/fulltext
ProPrems trial is very compelling as 95% of the study participants received breast milk!


Probiotic supplementation in preterm infants is perhaps the best studied yet least used therapy in neonatal medicine.¹, ² All recently published meta-analyses have reported significant impacts on important clinical outcomes.³, ⁴, ⁵ In the updated Cochrane meta-analysis,³ which includes 24 trials, there is a significant decrease in necrotizing enterocolitis (NEC) (relative risk [RR] 0.43, 95% CI 0.33-0.56; risk difference [RD] −0.03, 95% CI −0.04 to −0.02; P < .00001) and all-cause mortality (RR 0.65, 95% CI 0.52-0.81; RD −0.01, 95% CI −0.02 to −0.00, P = .01). Length of stay was 3-4 days shorter. There was no probiotic-related sepsis, although this is rarely reported outside trials.⁶

Probiotics are still infrequently used in North America. In 2012, only 8%-9% of very low birth weight (VLBW) infants in the Vermont Oxford Network received probiotics.⁷ It is time to consider changing guidance and practice.⁸ The authors of this editorial have differed on whether we have sufficient evidence to introduce prophylactic treatment. Tarnow-Mordi et al argued in 2010 that “the evidence that probiotics reduce mortality rates is as conclusive as that for surfactant for respiratory distress syndrome, cooling for hypoxic ischemic encephalopathy, or antenatal corticosteroids for threatened preterm labor.”⁹ In a companion commentary, Soll argued that the decision was far less clear.¹⁰ Trials had used multiple agents and doses. Few had studied extremely low birth weight infants, and few infants had received breast milk.
Many of these arguments have now been addressed. Wang reports subgroups of trials using Bifidobacteria alone, Lactobacilli alone, or the 2 combined.⁵ In all 3 subgroups, there were significant reductions, by about two-thirds, in the RR of NEC. The recently updated Cochrane Review includes 17 trials of >4900 VLBW infants.³ The RR risk of severe NEC for probiotics versus control was 0.41 (95% CI 0.31-0.56; RD −0.03, 95% CI −0.05 to −0.02; P < .00001). The treatment of 33 VLBW infants would prevent 1 case of severe NEC. The ProPrems study in 1099 very preterm infants in Australia and New Zealand is the largest ever randomized trial of probiotics.¹¹ Although there was no decrease in sepsis or the control mortality rate of 5.1%, the rate of NEC was halved (4.4% vs 2.2%; RR 0.46, 95% CI 0.23-0.93; P = .03), even though >95% of infants received breast milk.

Gavage Feeding-Continuous or Bolus?

It is a very well done in-vitro study published in 2010, yet has many practical implications.
Abstract

Substantial losses of nutrients may occur during tube (gavage) feeding of

fortified human milk. Our objective was to compare the losses of key macronutrients and

minerals based on method of fortification and gavage feeding method. We used clinically

available gavage feeding systems and measured pre- and post-feeding (end-point) nutrient

content of calcium (Ca), phosphorus (Phos), protein, and fat. Comparisons were made

between continuous, gravity bolus, and 30-minute infusion pump feeding systems, as well

as human milk fortified with donor human milk-based and bovine milk-based human milk

fortifier using an in vitro model. Feeding method was significantly associated with fat and

Ca losses, with increased losses in continuous feeds. Fat losses in continuous feeds were

substantial, with 40 ± 3 % of initial fat lost during the feeding process. After correction for

feeding method, human milk fortified with donor milk-based fortifier was associated with

significantly less loss of Ca (8 ± 4% vs. 28 ± 4%, p< 0.001), Phos (3 ± 4% vs. 24 ± 4%,

p < 0.001), and fat (17 ± 2% vs. 25 ± 2%, p = 0.001) than human milk fortified with a

bovine milk-based fortifier (Mean ± SEM).

Continuous Feedings of Fortified Human Milk Lead to Nutrient Losses of Fat, Calcium and Phosphorous.

Nutrients 2010, 2, 230-240; doi:10.3390/nu2030240Stefanie P. Rogers 1, Penni D. Hicks 2, Maria Hamzo 2, Lauren E. Veit 3 and Steven A. Abrams




  

Chorioamnionitis AND Retinopathy of Prematurity

http://www.karger.com/Article/FullText/357556

Abstract
Background: The role of chorioamnionitis (CA) in the development of retinopathy of prematurity (ROP) has not been well established. Objective: To conduct a systematic review and meta-analysis of the association between CA and ROP in preterm infants. Data Sources: The authors searched MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and PubMed, reviewed reference lists of relevant articles, abstracts and conference proceedings (Society for Pediatric Research, European Society for Paediatric Research 1990-2012), sought results of unpublished trials, and contacted the primary authors of relevant studies. Study Selection: Studies were included if they had a comparison group, examined preterm infants, and reported primary data that could be used to measure the association between exposure to CA and the development of ROP. Data Extraction: Two reviewers independently screened the search results, applied inclusion criteria and assessed methodological quality using the Newcastle-Ottawa Scale. One reviewer extracted data and a second reviewer checked data extraction. Summary relative risks (RRs) were calculated using a random effects model. Data Synthesis: We identified 1,249 potentially relevant studies from the electronic databases. Twenty-seven studies involving 10,590 preterm neonates with 2,562 cases of ROP were included. Taking into account all included studies without adjusting for gestational age (GA), CA was significantly associated with ROP (any stage) [summary RR 1.33 (95% CI 1.14-1.55, I² = 77%, p_{heterogeneity} < 0.0001)], and a borderline significant association was observed for severe ROP (stage ≥3) [summary RR 1.27 (95% CI 0.99-1.63, I² = 74%, p_{heterogeneity} < 0.0001)]. There was no publication bias with Begg's test. However, subgroup analysis of studies adjusting for GA showed no significant association on CA with ROP [summary RR 0.98 (95% CI 0.77-1.26, I² = 0%, p_{heterogeneity} = 0.89)]. Conclusion: Unadjusted analyses showed that CA was significantly associated with ROP (any stage) as well as with severe ROP (stage ≥ 3). However, the association disappeared on analysis of studies adjusting for GA. Hence, CA cannot be definitively considered as a risk factor for ROP, and further studies should adjust for potential confounding factors and report results by stage to clarify the association with severe ROP.

Postnatal Head Growth in Preterm Infants: A Randomized Controlled Parenteral Nutrition Study

http://pediatrics.aappublications.org/content/133/1/e120.abstract

BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (ΔHC) and HC SD score (ΔSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen.

METHODS: Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight <1200 1="" 28.="" 3.8="" actual="" assigned="" collected="" control="" daily="" data="" day="" days="" either="" for="" g="" gestation="" glucose="" hc="" intake="" kg="" lipid="" measured="" nutritional="" on="" or="" p="" per="" protein="" randomly="" regimen.="" remain="" scamp="" start="" the="" to="" was="" weekly.="" weeks="" were="">

RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater ΔHC at 28 days (P < .001). The difference between the means (95% confidence interval) for ΔHC was 5 mm (2 to 8), and ΔSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks’ corrected gestational age.

CONCLUSIONS: Early postnatal head growth failure in VPIs can be ameliorated by optimizing PN.

IVH outcomes in VLBW infants-Outcomes

http://pediatrics.aappublications.org/content/133/1/55.abstract

Intraventricular Hemorrhage and Neurodevelopmental Outcomes in Extreme Preterm Infants

on behalf of the New South Wales and Australian Capital Territory Neonatal Intensive Care Units’ Data Collection

OBJECTIVE: Not many large studies have reported the true impact of lower-grade intraventricular hemorrhages in preterm infants. We studied the neurodevelopmental outcomes of extremely preterm infants in relation to the severity of intraventricular hemorrhage.

METHODS: A regional cohort study of infants born at 23 to 28 weeks’ gestation and admitted to a NICU between 1998 and 2004. Primary outcome measure was moderate to severe neurosensory impairment at 2 to 3 years’ corrected age defined as developmental delay (developmental quotient >2 SD below the mean), cerebral palsy, bilateral deafness, or bilateral blindness.

RESULTS: Of the 1472 survivors assessed, infants with grade III–IV intraventricular hemorrhage (IVH; n = 93) had higher rates of developmental delay (17.5%), cerebral palsy (30%), deafness (8.6%), and blindness (2.2%). Grade I–II IVH infants (n = 336) also had increased rates of neurosensory impairment (22% vs 12.1%), developmental delay (7.8% vs 3.4%), cerebral palsy (10.4% vs 6.5%), and deafness (6.0% vs 2.3%) compared with the no IVH group (n = 1043). After exclusion of 40 infants with late ultrasound findings (periventricular leukomalacia, porencephaly, ventricular enlargement), isolated grade I–II IVH (n = 296) had increased rates of moderate-severe neurosensory impairment (18.6% vs 12.1%). Isolated grade I–II IVH was also independently associated with a higher risk of neurosensory impairment (adjusted odds ratio 1.73, 95% confidence interval 1.22–2.46).

CONCLUSIONS: Grade I–II IVH, even with no documented white matter injury or other late ultrasound abnormalities, is associated with adverse neurodevelopmental outcomes in extremely preterm infants.

Randomized Trial of Exclusive Human Milk versus Preterm Formula Diets in Extremely Premature Infants

http://www.jpeds.com/article/S0022-3476(13)00865-2/abstract

Objective

To compare the duration of parenteral nutrition, growth, and morbidity in extremely premature infants fed exclusive diets of either bovine milk–based preterm formula (BOV) or donor human milk and human milk-based human milk fortifier (HUM), in a randomized trial of formula vs human milk.

Study design

Multicenter randomized controlled trial. The authors studied extremely preterm infants whose mothers did not provide their milk. Infants were fed either BOV or an exclusive human milk diet of pasteurized donor human milk and HUM. The major outcome was duration of parenteral nutrition. Secondary outcomes were growth, respiratory support, and necrotizing enterocolitis (NEC).

Results

Birth weight (983 vs 996 g) and gestational age (27.5 vs 27.7 wk), in BOV and HUM, respectively, were similar. There was a significant difference in median parenteral nutrition days: 36 vs 27, in BOV vs HUM, respectively (P = .04). The incidence of NEC in BOV was 21% (5 cases) vs 3% in HUM (1 case), P = .08; surgical NEC was significantly higher in BOV (4 cases) than HUM (0 cases), P = .04.

Conclusions

In extremely preterm infants given exclusive diets of preterm formula vs human milk, there was a significantly greater duration of parenteral nutrition and higher rate of surgical NEC in infants receiving preterm formula. This trial supports the use of an exclusive human milk diet to nourish extremely preterm infants in the neonatal intensive care unit.

The fortifier used was breast milk based.

Good News For Ultrashortbowel Syndrome!

http://www.jpeds.com/article/S0022-3476(13)00678-1/abstract
Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE

Objective

To examine treatment outcomes in pediatric patients with ultrashort small bowel (USSB) syndrome in an intestinal rehabilitation program (IRP).

Study design

We reviewed IRP records for 2001-2011 and identified 28 children with USSB (≤20 cm of small bowel). We performed univariate analysis using the Fisher exact test and Wilcoxon rank-sum test to compare characteristics of children who achieved parenteral nutrition (PN) independence with intact native bowel and those who did not. Growth, nutritional status, and hepatic laboratory test results were compared from the time of enrollment to the most recent values using the Wilcoxon signed-rank test.

Results

Of the 28 patients identified, 27 (96%) survived. Almost one-half (48%) of these survivors achieved PN independence with their native bowel. The successfully rehabilitated patients were more likely to have an intact colon and ileocecal valve (P = .01). Significant improvements in PN kcal/kg, total bilirubin, and height and weight z-scores were seen in all patients, but serum hepatic transaminase levels did not improve in the nonrehabilitated patients.

Conclusion

Enrollment in an IRP provides an excellent probability of survival for children with USSB. The presence of an intact ileocecal valve and colon are positively associated with rehabilitation in this population, but are not requisite. Approximately one-half of patients with USSB can achieve rehabilitation, with a median time to PN independence of less than 2 years. The USSB population can attain reduced PN dependence, improvement of PN-associated liver disease, and enhanced growth with the aid of an IRP.

Get Gentamicin Trough Levels Before Administering The Next Dose In HIE With Therapeutic Hypothermia

http://www.jpeds.com/article/S0022-3476(13)00725-7/abstract

Study design

Data were collected prospectively in a regional center providing therapeutic hypothermia. Cooled infants at ≥36 weeks gestation with moderate or severe neonatal encephalopathy were analyzed if a full dataset was available (n = 108), including clinical variables and gentamicin trough levels. Infants with hearing impairment were identified, and survivors were followed up with neurodevelopmental evaluation at age 18 months. Stepwise logistic regression identified factors associated with hearing impairment.

Results

Nine infants died, and among the survivors, 10.1% developed a permanent hearing impairment. The trough gentamicin level was above the recommended cutoff of 2 mg/L in 37% of the infants in the entire cohort and in 90% of the infants with hearing impairment. Logistic regression analysis identified high trough gentamicin level, low cord pH, and hypoglycemia in the first postnatal hour as significantly associated with hearing impairment. The need for inotropic support was close to significant (P = .055).

Conclusion

Hearing impairment was a common finding among cooled infants. Plasma gentamicin levels were commonly >2 mg/L. Based on these findings, we propose changes in gentamicin dosing interval and trough level monitoring to minimize the risk of potentially toxic levels in cooled newborns.

Hyperoxemia within the First Hour of Life Is Associated with Moderate to Severe Hypoxic-Ischemic Encephalopathy

http://www.jpeds.com/article/S0022-3476(13)00508-8/abstract

see the editorial for this Oxygen Paradox (The phenomenon in which oxygen supplementation following a period of oxygen deficiency augments the injury is known as the “oxygen paradox.”) phenomenon at this link http://www.jpeds.com/article/S0022-3476(13)00701-4/fulltext

 120 infants at ≥36 weeks gestational age with perinatal acidosis born at Parkland Hospital who qualified for a screening neurologic exam for cooling therapy. Based on a PaO₂ measurement during the first hour of life, the cohort was divided into infants with hyperoxemia (PaO₂ >100 mmHg) and those without hyperoxemia (PaO₂ ≤100 mmHg).

Results

Thirty-six infants (30%) had an initial PaO₂ >100 mmHg. Infants with and without hyperoxemia had similar baseline maternal and infant characteristics. Infants with hyperoxemia had a higher incidence of HIE than those without hyperoxemia (58% vs 27%; P = .003). Admission hyperoxemia was associated with a higher risk of HIE (OR, 4; 95% CI, 1.4-10.5; adjusted P = .01). Among the neonates with moderate-severe HIE during the first 6 hours of life, those with hyperoxemia had a higher incidence of abnormal brain magnetic resonance imaging results, consistent with hypoxic ischemic injury, compared with those without hyperoxemia (79% vs 33%; P = .015).

Conclusion

In neonates with perinatal acidemia, admission hyperoxemia is associated with a higher incidence of HIE. Among neonates with HIE, admission hyperoxemia is associated with abnormal brain magnetic resonance imaging findings. The judicious use of oxygen during and after resuscitation is warranted.

Septicemia mortality reduction in neonates in a heart rate characteristics monitoring trial

http://www.nature.com/pr/journal/vaop/ncurrent/full/pr2013136a.html

Pediatric Research (2013) DOI:doi:10.1038/pr.2013.136

Background:

Abnormal heart rate characteristics (HRC) wax and wane in early stages of culture-positive, late-onset septicemia (LOS) in patients in the neonatal intensive care unit (NICU). Continuously monitoring an HRC index leads to a reduction in mortality among very low birth weight (VLBW) infants. We hypothesized that the reduction in mortality was due to a decrease in septicemia-associated mortality.

Methods:

This is a secondary analysis of clinical and HRC data from 2,989 VLBW infants enrolled in a randomized clinical trial of HRC monitoring in nine NICUs from 2004 to 2010.

Results:

LOS was diagnosed 974 times in 700 patients, and the incidence and distribution of organisms were similar in HRC display and nondisplay groups. Mortality within 30 d of LOS was lower in the HRC display as compared with the nondisplay group (11.8 vs. 19.6%; relative risk: 0.61; 95% confidence interval: 0.43, 0.87; P < 0.01), but mortality reduction was not statistically significant for patients without LOS. There were fewer large, abrupt increases in the HRC index in the days leading up to LOS diagnosis in infants whose HRC index was displayed.

Conclusion:

Continuous HRC monitoring is associated with a lower septicemia-associated mortality in VLBW infants, possibly due to diagnosis earlier in the course of illness.

Neonatal Hypoglycemia-Sugar Baby Study

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61645-1/fulltext

Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial.

The Lancet, Early Online Publication, 25 September 2013

doi:10.1016/S0140-6736(13)61645-1

Findings

Of 514 enrolled babies, 242 (47%) became hypoglycaemic and were randomised. Five babies were randomised in error, leaving 237 for analysis: 118 (50%) in the dextrose group and 119 (50%) in the placebo group. Dextrose gel reduced the frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0·57, 95% CI 0·33—0·98; p=0·04). We noted no serious adverse events. Three (3%) babies in the placebo group each had one blood glucose concentration of 0·9 mmol/L. No other adverse events took place.

Interpretation

Treatment with dextrose gel is inexpensive and simple to administer. Dextrose gel should be considered for first-line treatment to manage hypoglycaemia in late preterm and term babies in the first 48 h after birth.

Making of an Indian Pizza

Making of an Indian Pizza

Ingredients:

1)      Something that resembles Nan

2)      What on the earth is that!

3)      Tomato ketchup

4)      Grated cheese

5)      Peas

6)      Carrots

7)      Sliced onions

8)      Honey-not the one you are married to.

9)      Pasta sauce with garlic basil etc

10)   Last but not the least Trash can.

Buy a round or oval shaped Nan, available in any Indian grocery store. Please wash your hands, so that the guests can blame the contents and not the maker, if something happens to them after consuming this.

Next, smear I can’t believe it’s not Butter on the Nan (if it is not butter, what on the earth is that!). You may substitute with butter, if your coronary arteries are not completely blocked.

Then take tomato ketchup and smear it on the Nan, which is already smeared with what on the……

In the meantime, microwave carrots and peas (use small amount-usually frozen carrots pieces and peas). Now sprinkle grated cheese (I prefer four cheese Italian or pizza style grated) to cover the entire Nan surface. Now, pour some Pasta sauce with garlic, and medium spice chunky salsa on top of this layer. Use a generous amount, especially, if it has expired long back!!

You may add some sliced onions (microwaved) on this layer. Don’t let your honey come near the onions, least she may cry. If she cries, there is a fair chance your pizza will end up in the trash can.

Now, sprinkle some more grated fat free four cheese on top of this layer for longevity of your guests and spouse. If you choose to use full fat cheese-then give them Lipitor® for heaven’s sake.

Sprinkle the microwaved carrots and peas on top now. Squeeze your favorite honey on top of this. That’s why, it is not a good idea to squeeze the honey you are married to-otherwise she may end up as a widow!! You certainly don't want your wife to be widow, do you???

You may sprinkle some grated cheese on this layer so the vegies are buried and blend in with cheese. You may add some small amount of grated coconut, if you like.

Now put it in the toaster oven till the Nan turns brown and cheese has melted well. Frequently inspect to see if it has reached desired state; if it is too late, your trash can is always ready to enjoy your pizza.

Okay, why is it called Indian Pizza?

 

Because, it is made by an Indian! Say Cheese!

 

Blind Spot-Where Art Thou?

 

It was time for yet another vacation, albeit the first one for this year. After much haggling and scratching the bald head, we decided to go to a beach city on a strip of a land in the ocean. We decided to avoid the most popular parts of the beach for the sake of quietness and enjoy the nature without the need for threadbare dressing. After all, we have packed our bags with clothes, and why not put them to use.

However, it appears the purist nudists are lobbying the airlines to charge those who believe in covering themselves. They penalize you for extra clothes for extra length of stay with higher second baggage fee. We find no resistance forthcoming from the government even. Hotels are actually cheaper, where Adam and Eve roam, and more expensive if you cling to the strings. It’s a double whammy! Not only the clothes are costly, you are chastised for carrying them too. Since, it was too far to drive, we flew paying the retribution. This unholy nexus should be bared, I thought! But, how can we expose those, who are already exposed? That’s a naked dilemma!

Finally, we reached the most expensive part of the city and drove to our likeminded resort. There were plenty of leaves, yet, everyone preferred cotton to cover. We felt at home, and were mesmerized by the amazing ocean views from our room. Beautiful nature baring before us, we could not resist any longer. We stepped out of the resort to walk on the beautiful beach. We were greeted by the sign- There is no life guard on duty, which meant-if you dive, you die. It struck me that I did not write my “Will” yet. Without a will, I had no will to step in to the willful waters. I have only one life to guard, oh God, there is no life guard here. Basically, resort people were anti-nudists, I thought. They seemed to have felt, if they provided a life-guard, people may be tempted to wear their birthday-suits rather than bathing suits.

I was provided with a beach lounge chair with canopy for ample shade, least my dark skin may get tanned. We were the most well-dressed couple on the beach, thanks to our two extra bags of garments, we painfully paid penalty for. I was carefully relaxing and enjoying the unguarded ocean. Whereas, my wife unmindful of her dress or absence of life-guard jumped in to the waters. She began to have a treat with the tides. She looked around and found me missing the fun with whoopee waves. Innocently, she began to request me to take the dangerous plunge. She was so insistently persistent, others around were inspired to throw me in to the bare ocean. Sensing the imminent sacrifice, I gently stepped in to the warm waters of Atlantic.

Walking in to the lobby, it became apparent that English was a foreign language here. Suddenly, I felt as if I had drifted off to a French or a Dutch island while asleep. I had an eerie thought- should I have brought my passport? Actually, this stirred me to speak in my mother tongue freely. Energized by the wave currents, we proceeded to the upscale mall barely 100 yards from our resort. We decided to buy something nice to commemorate anti-nudist stance, we all believed in.

As we walked in to one of the upscale brand shops, we noticed customer service was busy putting up a sign- 70% off for a wrinkled cotton polo shirt, which is now just a mere $245 after the whopping discount. Are purist naturalists influencing the garment industry as well? Or, this exorbitantly extortionate expense pushed them to more au-naturel dressing! The dilemma for us was- to bare or to wear!! The customer service was completely oblivious to our presence. Either it was our bewilderment at the bankrupting bill beetling before us making us potential non-buyers, or, we could be wearing invisible cloaks, and she could not see us. Scared that we may have to sell our neighbor’s house as well to purchase decent clothing for our family, we hurriedly left the shop.

We saw some of the finest dream cars entering the mall premises. They were so beautiful and yet so depressing. As we reached the pedestrian crossing, we saw a young mother who was trying to cross with a baby in her stroller. She had stilettos and had poignant ramp walk like stride. Soon, a mesmerizing Maserati began to meander in her direction. It never slowed and maintained its speed to cross before the equally stylish mother. As it approached dangerously close, the lady shed her sophisticated style and stilettos and sprung like a skillful Olympic sprinter letting out a shrill shriek. The majestic Maserati continued its unperturbed serene sojourn. Before, we could recover from this horrendous happening, a royal Rolls Royce began to roll towards an old couple. Before Olympic spirit could spring in them, a policeman jumped in front of the royal beast like a superman to move the old couple to safety. The driver however, maintained his dispassion and the automobile its aplomb. It was obvious that neither the countess nor the couple were adorning invisible cloaks, as policeman could see and intervene. Since, none of the motorists were unruffled, it appeared to us that these deadly dream machines are so engineered that the blind spots could be in the front, unlike in our peasant cars. You have to be super rich to be in one of these cars and a superman to be in their front! Whether you pay fair fare for what you wear or stare at the bare, no one may care. But, these blind spots, you better be aware!

 

                                                                                  

Peditools for Fenton Growth Chart 2013

http://peditools.org/fenton2013/

http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx

What Can A Watch Do For You?

I personally believe that watch is a waste of space on my wrist if it only shows time. May be for guys like me, watches are doing lot more than just tell me time. I have used several smart watches in the past. Majority of them were stand alone smart watches. One of them was bluetooth watch with headset. It literally stopped people in their tracks to enquire which company sells such phones.
It finally died. I then bought Microsoft SPOT watch. It showed time, weather in real time, news events locally, movie listings, stock prices in real time. However, Microsoft decided abandon the service. I was left with no choice than to buy a watch with built in phone. It made me lose privacy, as lot of people waited for me to finish my conversation just to get more information about this incredible watch phone. However, it was cumbersome to enter the contacts and search. So, I abandoned.
Now, we have a much better choice-The PEBBLE.
It is a smart watch which connects with your cell phone through bluetooth. You can receive SMS, email, reminders besides caller ID on your watch. It conveniently vibrates and alerts you to incoming call or message. You can read the entire sms on the phone itself.
You may say, why are you so lazy to look at your phone, which is just in your pocket. There are few good reasons. 1) the phone is not always in your pocket, such as when home, 2) when driving, and 3) when in a meeting, you don't want to take your phone to see who is calling.
How does this new smart watch help me in day to day life?
1)Wherever, I am it helps me not to miss a call especially from my wife and from the hospital.
2) I can read the SMS without taking out my phone.
3) In a meeting, as my phone is always in a vibratory mode, I am not embarrassed by sudden unexpected call.
4) The weather is always updated on my watch as frequently as I want.
5) I get reminders for the things I need to accomplish. Put trash outside on certain days.
6) I can look at the calendar in one convenient glance.
7) I can program one of the buttons to make a call through my phone, without getting distracted, while driving. You can program up to three frequently used numbers and just press a button, it wakes up your phone and makes a call to that specific phone number without much of your involvement. the call comes through your car speakers. currently, you need to press a voice command button, and then give directions to the voice recognition and confirm that it recognized the number, which is always a hassle and unsafe.
8) I can wake up to an alarm as it conveniently vibrates on my wrist.

Thus, I am really enjoying this watch more than my smartphone. Martain passport watch has a speaker on the watch and you can send commands to SIRI on your Iphone and make calls and even converse through your wrist watch, which is bit too geeky though for me. Basis band watch records all your activities like Fitbit. So, choose your style and enjoy. I have a feeling that Pebble may more useful for women as many of them keep their phones in a purse and may miss important  text messages or calls.
UPDATE: Now we have a find the phone feature on Pebble. It is a very neat one to locate your smartphone. You can even take photo with press of a button without taking the phone out.