Day 1 :
Keynote Forum
Igor Klepikov
Pediatric Surgeon, Russia
Keynote: Revision of the doctrine of acute pneumonia-an inevitable prerequisite for solving the problem
Time : 10:00-10:45
Biography:
Igor Klepikov worked as Pediatric Surgeon in Russian State Institute for Post-Graduate Medical Studies Novokuznetsk (Russia) and in Tel-Aviv Medical Center (Israel). Igor did research in Public Health, Respiratory Medicine and Pulmonology. Continuation of these studies is the current project- "the new doctrine of acute pneumonia-a guarantee of prevention of purulent and destructive complications." Igor Klepikov was born and studied in the USSR. Pediatric Surgeon is the highest qualification in Russia and Israel with experience of over 40 years, MD, professor. He published over 140 scientific publications, patents and 2 monographs. Doctor of Science (post-doctoral degree) in 1989 and Ph.D. in Medicine in 1980 at Residency in Pediatric Surgery - State Institute for Postgraduate Medical Studies Novokuznetsk, USSR, Russia. Medical Doctor (M.D.) in 1971 at State Medical Institute Kemerovo, USSR, Russia
Abstract:
Excessive fascination with antibiotics as a universal remedy gradually and imperceptibly narrowed the perception of the nature of many diseases.Тo date, the main treatment of acute pneumonia (AP) is similar to the treatment of diseases with fundamental differences in their localization, mechanism of development and clinical manifestations, and the result of medical recommendations is an elementary empirical distribution of antibiotics between different categories of patients. Such a primitive approach to treatment inevitably led to the transformation of views on the nature of AP, which in recent years is increasingly interpreted not as an inflammatory, but as an infectious process.
Localization of ÐP in the vascular system of the small circle of blood circulation is its fundamental difference from other inflammatory processes, even in the case of identical pathogens. Reducing the effectiveness of antibiotics and increasing resistance to them microflora every year increase the relevance of this problem. The persistence of high rates of morbidity and mortality in ÐP, the steady increase in the number of complicated forms, the collapse of hopes for vaccination and the lack of strategic proposals to overcome this situation allow us to consider the study of thirty years ago worthy of close attention of experts. The biological laws of inflammation, already well studied, proven and accepted in the form of classical definitions, have worked, act and will act independently of our perception. Ignoring these stereotypes leads us in the wrong direction from solving the problem.
This work was performed and tested in clinical conditions in 1976-1985 in the clinic of pediatric surgery at The state Institute of advanced training of doctors (Novokuznetsk, USSR). Life circumstances did not allow the author to continue the research, to develop the achievements and to present the results at the international level in a timely manner. The main and first step in the study was a radical revision of views on the nature and mechanisms of development of ÐP. The new doctrine was based on well-known scientific medical axioms and facts that already had the previous justification and confirmation.
In addition, the following studies were carried out:1.Experimental model AP (4 series of experiments, 44 animals) to obtain a model of pleural complications (certificate for invention â„– 1631574,A1, November 1,1990, USSR).2.X-ray examination with contrast of 56 anatomical lung preparations with various forms of AP taken from deceased patients.3.Record of comparative rheopulmonography before and after treatment procedures (36 patients).4.Analysis of monitoring and treatment of 994 children with AP and its various destructive and pleural complications.
The revised treatment guidelines were applied in 101 patients in the initial period of aggressive forms of ÐP. The analysis of the results showed that compared with the same group of patients who received the previous complex of care, the number of pleural and pulmonary complications significantly decreased ( T = 8,65; P < 0,001), the length of hospital stay was reduced by three times, respectively, material and financial costs of treatment were significantly reduced, there were no deaths. The received results allow to speak about possibility of the guaranteed prevention of suppurative and destructive complications of the disease.
The revised treatment package was also used in 102 patients who already had pleural changes at the time of hospitalization, despite the initial period of the disease. In this group of patients, rapid recovery without lethal outcomes was also achieved, but the final results depended on the nature of initial pleural changes.
A more detailed presentation and justification of the new doctrine AP, the results of these studies and clinical trials can be found in the published book.
Keynote Forum
Suhas Kulkarni
D Y Patil Medical College, India
Keynote: Respiratory problems and use of impulse oscillometry in children 3 years to 6 years old
Time : 10:45-11:15
Biography:
Suhas Kulkarni is working as an Associate Professor in the Department of Pediatrics at D Y Patil Medical College, Kolhapur, India. He is done various publications and detailed projects which are related to the field of Pediatrics.
Abstract:
Introduction: Measurement of lung function is an important component in the decision making process of obstructive airway diseases. It helps in arriving at a specific diagnosis, choosing pharmacotherapy and assessing prognosis .It can also help in assessing response to therapy.
Recent studies have brought into question the WHO guidelines regarding treatment of pneumonia which may result in over diagnosis of pneumonia and an over prescription of antibiotics at the expense of asthma and wheezing.
Objectives: Use of Impulse oscillometry to differentiate between pneumonia and wheezing in 3-6 years old children.
3-6 years old children with history of wheezing, fast breathing, breathlessness fulfilling inclusion criteria and whose parents give consent for study were included.
- History of patient regarding fever, cough, and fast breathing wheezing episode was taken. Past history of similar episode. History of atopy in child and parents was asked. (Regarding atopic dermatitis in child and atopic dermatitis, allergic rhinitis and bronchial asthma in parents).
- Thorough clinical examination of respiratory system was done. Appropriate investigations were done. Pulse oximetry was carried out.
- Impulse oscillometry was done on day 1, before and after nebulization with a bronchodilator. If the consent was given by the parent’s skin prick test and serum IgE were done in atopic cases for confirmation.
- Results: 51 children fulfill the inclusion criteria.5 children did not perform the procedure optimally. Hence 46 patients were analysed.23 boys and 23 girls were present. Cold as a symptom was useful in differentiation. P value < 0.05.Cough as a symptom was not useful for differentiation. P value =0.915.Fever as a symptom affects final diagnosis p value < 0.005.Breathlessness as a symptom cannot differentiate between the wheezing episode and bronchopneumonia p value >0.05 .Heart rate was found to be insignificant. Respiratory rate was found to be significant p value < 0.05...
The resonant frequency before and after nebulization was found to be significant .The p value was <0.1
- The change in R 5 before and after nebulization: Paired T test was used to test change in R at 5 Hz. P value : 0.001678
- Conclusion: Significant change in average of R at 5 Hz pre and post use of bronchodilator.
- Paired T test was used to test change in R at 20 Hz.
- Conclusion : No significant change in average of R at 20 Hz pre and post intervention
Conclusion: With proper history and clinical examination and use of impulse oscillometry it is possible to differentiate between wheezing episode and bronchopneumonia. It was found that symptoms fever and cold affects the final diagnosis but age ,sex, cough and breathlessness does not affect the final diagnosis .In signs respiratory rate measured by the clinician significantly affects the final diagnosis but heart rate does not affect the final diagnosis. The difference between parameters checked by impulse oscillometry R at 5 Hz, AX and resonant frequency before and after nebulization was able to differentiate between bronchopneumonia and wheezing episode. .It helps to objectively show the response to bronchodilator which gives an indication which child requires treatment with only bronchodilator and which child requires antibiotics .This approach can save lot of unnecessary treatment and admissions.
- Pediatrics and Clinical Pediatrics | Pediatric Cardiology | Pediatrics Critical Care and Emergency Medicine | Pediatrics Diagnosis | Pediatric Nutrition and Breast Feeding
Location: London, UK
Session Introduction
Ankit Agrawal
Madhya Pradesh Medical Science University, INDIA
Title: Relationship between Newborn Mid-upper-arm-circumference (N-MUAC) and Newborn birth weight.
Biography:
Ankith Agrawal went to Madhya Pradesh Medical Science University, INDIA, he is interested the fields of General Pediatrics, Pediatric Surgery and Neonatology. He published several articles related to Pediatrics and Neonal Care.
Abstract:
BACKGROUND: Recording an accurate birth weight by primary health worker has been a problem in rural areas, leading to search for alternative inexpensive, age independent and non invasive method to predict newborn birth weight and well being.
Objective: Relationship between Newborn Mid-upper-arm-circumference (N-MUAC) and Newborn birth weight. .
Study Design: Prospective observational study
Participant: Total of 1303 Intramural newborns admitted in SNCU Kamla Raja Hospital, G.R. Medical College, and Gwalior (M.P) were studied.
Intervention: The Mid upper arm circumference (MUAC) of newborns were taken and Birth weight recorded were filled in a proforma.
Result: Total of 1303 newborns were included in the study. The mean MUAC and birth weight in preterm is found to be 1854.80+387.3 and 7.47+0.9 as compared to full term newborn who is having mean birth weight(2818.95+328.1) and mean MUAC (9.58+0.7).The correlation coefficient between neonatal MUAC (N-MUAC) and birth weight is found to be r=0.987 and p<0.01.Birth weight can be predicted from regression equation: Birth weight (gms)=422.99 (N-MUAC) +(-1272.66).Cut-off value of neonatal mid upper arm circumference(N-MUAC) was found to be 8.85cm to predict low birth weight neonate.
Conclusion: Birth weight of neonate can be predicted from neonatal mid upper arm circumference (N-MUAC) in areas where the conventional scale are not easily available for measuring the birth weight of neonate.
Keywords: MUAC, Birth weight
Fazal-e-Rabi Subhani
The Rotunda Hospital, Ireland
Title: Role of adjunctive glucocorticoid therapy in central nervous system tuberculosis
Biography:
Fazal-e-Rabi Subhani is currently working as a Pedestrian at The Rotunda Hospital in Rotunda, Dublin, Ireland. He has done various publications and research works in the fields of infection.
Abstract:
Introduction: Central nervous system (CNS) tuberculosis (TB) is a frequently encountered infection in the regions of the world where the prevalence of post-primary dissemination is common among children & adults. It includes three clinical categories: tuberculous meningitis, intracranial tuberculoma, & spinal tuberculous arachnoiditis. In CNS TB intense hypersensitivity reaction with consequent significant inflammatory changes are known to develop in the subarachnoid space due to the spillage of tubercular protein explaining the potential need for adjunctive glucocorticoid therapy to help reduce the case-fatality ratio, which over years have remained relatively high (15-40%) despite effective antimicrobial regimens.
Method: A comprehensive search of PubMed & EMBASE from their inceptions to October 2019 was made using 3 search items: glucocorticoid therapy, tuberculous meningitis, & intracranial pressure. The search items were combined using the Boolean operator. A further search was made of the United States Centres for Disease Control & Prevention (CDC), Cochrane Database Syst Rev, World Health Organization guidelines, & ClinicalTrials.gov with no language restriction.
Results: Randomized control trials (RCTs) have demonstrated a mortality benefit when adjunctive glucocorticoid therapy is used in HIV-uninfected CNS TB patients. Since data in HIV-infected patients is sparse, the same mortality benefit has not been reproduced thus far in such cases. In a systemic review including nine trials (1337 patients with CNS TB), adjunctive glucocorticoid therapy was associated with a lower mortality rate (risk ratio 0.75, 95% CI 0.65-0.87). In a RCT from Vietnam (545 patients with CNS TB), lower mortality rate was observed in patients who received dexamethasone (32 versus 41 percent; relative risk 0.69, 95% CI, 0.52-0.92). In a RCT from South Africa (141 children with CNS TB), lower mortality rate was observed in patients who received prednisolone (4 versus 17 percent). Additionally, children who received steroid therapy were more likely to have subsequent IQ >75 (52 versus 33 percent).
Conclusion: There is good quality evidence now available supporting the use of adjunctive glucocorticoid therapy in patients with CNS TB (confirmed or suspected). Reducing doses of first intravenous (IV) Dexamethasone for one month & then oral for one month remains the regimen of choice: 0.3-0.4 mg/kg/day IV x 2 weeks, then 0.2 mg/kg/day x 1 week, then 0.1 mg/kg/day x 1 week, then 4 mg/day orally x 1 week tapering 1 mg off the daily dose each week thereafter (total duration approximately two months).
Fazal-e-Rabi Subhani
The Rotunda Hospital, Ireland
Title: Management and prognosis of perinatal stroke
Biography:
Fazal-e-Rabi Subhani is currently working as a Pedestrian at The Rotunda Hospital in Rotunda, Dublin, Ireland. He has done various publications and research works in the fields of infection.
Abstract:
Introduction:
Perinatal stroke refers to an acute neurological syndrome with chronic sequelae that develops between 20 weeks gestation & 28 days post-partum caused by cerebral injury of vascular origin (arterial thromboembolism, cerebral sinovenous thrombosis [CSVT], or primary intracranial haemorrhage [ICH]). Wide variations in morbidity & mortality rates are seen following perinatal stroke depending upon the location & extent of brain injury. Chronic disabilities may include cerebral palsy, epilepsy, cognitive impairment, behavioural & mood disturbances, visual problems & language issues.
Method:
A comprehensive search of PubMed & EMBASE from January 2000 to October 2019 was made using 3 search items: perinatal stroke, antithrombotic therapy in neonates & children, & stroke rehabilitation. The search items were combined using the Boolean operator. A further search was made of the society guidelines of American Heart Association/American Stroke Association, American College of Chest Physicians, Canadian Stroke Association, Cochrane library, & ClinicalTrials.gov with no language restriction.
Results:
The mainstay of treatment in perinatal stroke cases is supportive care aimed at preventing further cerebral injury by ensuring adequate oxygenation and correction of dehydration, electrolytes imbalances, metabolic disturbances, hypoglycaemia, hypocalcaemia, & anaemia. Antibiotics are given if infection is suspected. Anticonvulsants are given if seizures are seen or suspected (prolonged video-electroencephalogram monitoring may be necessary as clinical identification of seizures is unreliable in neonates). Unlike adults, most thromboembolic perinatal strokes do not recur or progress. Antiplatelet therapy, anticoagulant therapy, thrombolysis & mechanical thrombectomy (the usual treatment options in adults) are therefore not indicated in significant majority of perinatal stroke patients. Rare indications of antithrombotic therapy include underlying thrombophilia, complex congenital heart disease (NOT including patent foramen ovale), & atrial fibrillation. Antithrombotic treatment options include aspirin, unfractionated heparin (UH) & low molecular weight heparin (LMWH). CSVT cases require treatment with UF or LMWH even when significant secondary haemorrhage has developed. ICH cases require vitamin-K (in all), correction of severe thrombocytopenia (if present) & replacement of clotting factors (if any deficiencies are found). Those who develop hydrocephalus are initially treated with ventricular drainage, followed by ventriculoperitoneal shunting if hydrocephalus persists. Other interventions beyond the neonatal period may include surgery for drugs-resistant epilepsy & embolization of arteriovenous malformations.
Conclusion:
Long-term neuro-developmental outcomes are normal in only 19-41% of thromboembolic perinatal stroke cases. Frank hemiparesis and mild neuromotor dysfunction are respectively seen in approximately 25-30% & 30% cases. Perinatal ischaemic stroke is the commonest known cause of cerebral palsy accounting for roughly 30% of hemiplegic cerebral palsy cases amongst babies born at term. Survivors of perinatal ischaemic stroke are known to exhibit below-average IQ scores (mean 87 versus mean 100, in normal subjects). The estimated prevalence of epilepsy following perinatal ischaemic stroke is 10-40% during acute phase & 19-67% later in life. Although 93-97% of newborns with CSVT survive the acute phase, in one study, the mortality rate was 19% when followed-up at a mean age of 19 months. Prognosis in ICH cases is even worse with multiple studies showing mortality & morbidity rates ranging between 4-15% & 44-77% respectively.
Biography:
I have completed my MD training in Sackler school of Medicine in Tel Aviv University in 2014, and started my residency in Pediatric medicine on 2015. During my training I have completed a comprehensive point of care ultrasound course in Soroka University Medical Center affiliated to Ben Gurion University, which focused on FAST exam, cardiac, lung and vascular POCUS. As a future fellow in Pediatric emergency medicine, with the aim to improve and perfect this art of ER subspecialty, I designed with other experts in the field this short termed simulation based training in POCUS, which proved extremely efficient and productive. I truly believe this work will demonstrate the tremendous effect of POCUS training on the professional skills of residents in Pediatric medicine, and will encourage other hospitals around the world to initiate such programs.
Abstract:
Objectives: Focused assessment with sonography for trauma (FAST) has been integrated into the primary assessment of pediatric trauma patients in the emergency department. Various studies show that the FAST skills can be acquired after a short training period in populations such as interns and medical students. however, few data exist on the retention of ultrasound skills over time. This study evaluated the retention of FAST skills and knowledge of pediatric residents 6 months after completing a simulator based training program.
Methods: This is a prospective cohort study. subjects completed successfully a short simulator based training program of FAST examination. Skills were retested 6 months and compared with previous results to assess skill retention. Competence was evaluated by a simulator-based test. Integration of knowledge was evaluated by a written multiple-choice test.
Results: 16 of 19 (84.2%) subjects completed follow-up testing. Although Performance declined in image acquisition, still 91% of trainees maintained their skill 6 months after training. Interpretation skills declined more severely from 98.2% to 78.9% after 6 months. 25% of Participants stated that they are using FAST regularly.
Conclusions: retention of FAST skills are partially sustained after 6 months of non routine use. A short training program is sufficient for gaining the skills but a routine use is needed to ensure competence
Biography:
Ofri has completed her MD at the age of 30 years from TEL AVIV University, Sackler School of Medicine. She is currently in her 3rd year of residency in Pediatric medicine, in Meir medical center, Israel.
Abstract:
Backround: the use of Point of care Ultrasound (POCUS) is becoming increasingly widespread In emergency medicine. this is mainly due to its safety, minimal invasiveness, high accuracy, and its ability to provide a binary diagnostic result.
Limping or Pain in limb accounts for approximately 1.8/1000 of pediatric ED admissions. This is a very challenging diagnostic entity that often results in extensive and futile diagnostic workup because of its wide differential diagnosis. Therefore, POCUS provides an excellent opportunity to help avoid unnecessary tests and thus significantly shorten ED care duration.
Methods: In this retrospective cohort, performed at pediatric ED in major regional center, 335 cases of limping or pain in limb were included between 2015-2019. The cases were divided to 2 major groups: patients who underwent HIP POCUS (POCUS group), and those that underwent standard accepted workup (CONTROL group). Statistical analysis of the population was conducted (t-test and chi-square comparisons) while primary outcome was care duration in the ED and additional diagnostic workup.
Results: 135 cases underwent HIP POCUS between 2017-2019, and 200 cases underwent standard diagnostic procedure between 2015-2017. The mean age of POCUS group was 6.6 years (SD 3.5), while of CONTROL group 7.5 years (SD 1.5) with no significance difference. The groups didn’t differ significantly in their gender, ethnicity or clinical presentation (fever, prior minor trauma, prior upper respiratory tract infection, and hip joint tenderness on physical examination). Primary outcome significantly differed between the groups with shorter duration in POCUS group (166±90 min. vs 215±105 min. p<0.0001, CI 27.14-71.59). additional tests: blood sampling, orthopedic counseling and formal ultrasound were significantly more abundant in the CONTRROL group (p<0.0001 for each test, chi-square test).
Conclusions: our results suggest that utilization of POCUS is of high clinical potential to reduce unnecessary tests and shorten duration care in the pediatric ED.
Tetinou Djifack Francklin
Department of Neurosurgery, Cameroon
Title: Etiology and comorbidities on epileptics children at the yaounde gyneco-obstetrics and pediatrics hopital
Biography:
Tetinou Francklin Cameroonian medical doctor interested in neurosurgery, neurotrauma and Neuropediatrie. Research Department in Association of Future African Neurosurgeons and aspiring neurosurgeons
Abstract:
Objectives
Epilepsy etiologies in underdeveloped countries are much more symptomatic, compare to in developed country where they are largely idiopathic. Several comorbidities occur on epileptic children due to brain damage and antiepileptic drugs. These comorbidities worsen the prognosis of these children on varying degrees. The main comorbidities are mental retardation, psychiatric disorders and malnutrition. Very few studies in Cameroon to date have been devoted to comorbidities in children with epilepsy. Faced with this lack of data, we proposed to conduct this study whose objective was to describe the etiologies and mains comorbidities in children with epilepsy followed at the Yaoundé Gyneco-Obstetrics and Pediatric Hospital.
Methods
In this cross-sectional study, we interviewed a consecutive sample of 159 children with epilepsy and their parents at the Yaoundé Gyneco-Obstetrics and Pediatrics Hospital. The study was conducted from January 15 to May 14, 2019. The data were recorded and analyzed by the WHO anthro software with which we calculated patient z-scores and Epi info version 3.5.3. Chi 2 and Fischer Exact tests were used to measure the association between epileptic syndromes and comorbidities on the one hand, and between the etiologies of epilepsy and comorbidities. Logistical regression has eliminated the confounding factors. The Odd Ratio expressed with its 95% confidence interval was used to determine the degree of association between variables.
Results
The average age was 6 years. Anoxo-ischemic encephalopathy was the main cause of epilepsy (28%), followed by status epilepticus (6.9) and severe malaria (6,3).
Mental retardation was the main comorbidity (52%) followed by cerebral palsy (31%), attention deficit hyperactivity (30%), malnutrition (24%), depression (9.4%). Malnutrition was most pronounced in children with epileptic encephalopathy (34%). West syndrome increased by 22 and 18 the risk of having mental retardation (P -0.000), and cerebral palsy (P - 0,000), respectively. Others epileptics encephalopathies were also associated with cerebral palsy (OR - 13.3; and malnutrition (OR - 3.59; P-0.04). Anoxo-ischemic encephalopathy was the main etiology of epilepsy and it increased by 11 the risk of having cerebral palsy (P -0.000) and by 2.3 and 5 the risk of malnutrition (P-0.03) and mental retardation (P-0.000) respectively.
Conclusion
The main etiology of childhood epilepsy is anoxo-ischemic encephalopathy. Comorbidities in children with epilepsy are a real public health problem with mental retardation, attention deficit hyperactivity, malnutrition and depression as the main comorbidities. We recommend that the Ministry of Public Health combat perinatal asphyxia, which is the main cause of epilepsy, by strengthening the national health policy focused on emergency obstetric and neonatal care. To doctors, to strengthen the follow-up of these children and look for mental retardation, attention deficit hyperactivity, and malnutrition in children with epilepsy and especially in those with epileptic encephalopathy.
Fazal-i-Akbar Danish
Altnagelvin Area Hospital, Ireland
Title: Therapeutic considerations in non-o1/o139 vibrio cholera infections
Time : 3:30-04:00
Biography:
Fazal-e-Rabi Subhani is currently working as a Pedestrian at The Rotunda Hospital in Rotunda, Dublin, Ireland. His main works are into the field of pediatrics and he has published many articles for the same.
Abstract:
Introduction:
Vibrio cholerae is a highly diverse species. Whereas almost all cholera-causing strains fall in the serogroups O1 & O139, outbreaks of potentially fatal ‘cholera-like illnesses’ have been reported in estuarine environments in multiple parts of the world with lesser known non-O1/non-O139 serogroups. Phylogenetic studies suggest that all cholera-associated strains tend to cluster closely together in keeping with the concept that the outbreak of an epidemic illness requires the presence of an ‘epidemic genotype’ that comprises of multiple genes coming from a host of serogroups. Non-O1/non-O139 serogroups have been associated with gastroenteritis (either caused by faecal contamination of food & water, or eating raw or undercooked shellfish) and wound infections (caused by environmental exposure to contaminated water). Gastroenteritis/wound infection in turn can lead to septicaemia almost exclusively in immunocompromised patients or in patients with severe underlying liver disease.
Method:
A comprehensive search of PubMed & EMBASE from their inceptions to October 2019 was made using 3 search items: non-O1/non-O139 Vibrio cholerae, cholera outbreaks, & heat wave-associated vibriosis. The search items were combined using the Boolean operator. A further search was made of the United States Centres for Disease Control & Prevention (CDC) website, & ClinicalTrials.gov with no language restriction.
Results:
Mild gastroenteritis in immunocompetent patients often requires nothing more than fluid resuscitation (oral or intravenous depending upon the need). In severe diarrhoeal illnesses, however, empirical antibiotic therapy with doxycycline is known to reduce the duration of the illness & is therefore recommended pending susceptibility testing results. Alternatives include macrolides & fluoroquinolones. Wound infections even when mild require both debridement & empirical antibiotic therapy with tetracycline or macrolide for 5-7 days. Immunocompromised patients or those with severe underlying liver disease are at risk of developing septicaemia therefore mandating admission to intensive-care unit (ICU) & aggressive combination antibiotic therapy with either minocycline or doxycycline (100 mg orally twice daily), plus a third-generation cephalosporin (either cefotaxime 2 g IV 8 hourly or ceftriaxone 1 g ID once daily) for 1-2 weeks (or even longer) depending upon the response.
Conclusion:
In immunocompetent patients, diarrhoeal illness is often mild & self-limiting. Likewise, wound infections generally respond well to debridement & oral antibiotic therapy in immunocompetent patients. Immunocompromised patients or those with severe underlying liver disease, however, are at most risk of death and therefore require aggressive treatment in ICU settings. Given increasing rates of resistance to antibiotics, susceptibility testing should be performed to rationalize antibiotic selection in all cases. In resource-rich settings, non-O1/non-O139 Vibrio cholerae infections can be prevented by avoiding consumption of raw or undercooked shellfish. In resource-limited settings especially in the coastal areas, prevention will require avoidance of environmental exposure to contaminated water & cross-contamination of food by seafood.
Fazal-e-Rabi Subhani
The Rotunda Hospital, Ireland
Title: Optimal management approach for patent ductus arteriosus in preterm infants
Time : 04:30-05:00
Biography:
Fazal-e-Rabi Subhani is currently working as a Pedestrian at The Rotunda Hospital in Rotunda, Dublin, Ireland. His main works are into the field of pediatrics and he has published many articles for the same.
Abstract:
Introduction:
Hemodynamically significant patent ductus arteriosus (PDA) in preterm infants is known to be associated with greater mortality and substantial morbidity in the form of pulmonary oedema/haemorrhage, bronchopulmonary dysplasia (BPD) and potential end-organ ischaemic injury. Considerable practice variability exists regarding different PDA management approaches from supportive care alone to pharmacological closure to surgical ligation.
Method:
A comprehensive search of PubMed & EMBASE from their inceptions to October 2019 was made using 3 search items: patent ductus arteriosus, preterm infants, & management approaches. The search items were combined using the Boolean operator. A further search was made of the Cochrane Central Register of Controlled Trials, & ClinicalTrials.gov with no language restriction.
Results:
Literature review suggests that the most appropriate management approach is a step-wise strategy beginning with supportive care provided to all preterm infants including a neutral thermal environment, moderate fluid restriction (110-130 mL/kg/day) & adequate respiratory support (target SpO2 90-95%, PaCO2 55-65 mmHg, pH 7.3-7.4, & haematocrit above 35%). The next step is pharmacological closure attempted in infants who remain ventilator-dependent after one week. It is done in the form a course of non-selective COX inhibitors therapy (indomethacin, ibuprofen), or paracetamol. Latter is generally considered if COX inhibitor therapy is considered contraindicated (untreated infection, NEC, active bleeding, thrombocytopenia, significant renal impairment, concomitant congenital heart disease like pulmonary atresia, severe tetralogy of Fallot, severe coarctation of aorta). An echocardiogram is performed 1-2 days after completion of drug course. If it shows PDA closure, a positive response to therapy is confirmed. Unfortunately, a significant proportion of infants fail to respond to the initial course as evidenced by visualization of persistent PDA on follow-up echocardiogram & infants remaining ventilator-dependent. Limited date suggests that a second course of COX inhibitor is associated with 40% rate of ductal closure in such instances. Infants who fail to respond to even the second course & remain ventilator-dependent on maximum settings are unlikely to respond to drug treatment & therefore no further medical therapy is considered appropriate in such instances. Although rarely necessary in real life, surgical ligation should be considered in these cases.
Conclusion:
Head-to-head comparison of different drugs used to attempt pharmacological closure of PDA (indomethacin, ibuprofen, & paracetamol) is particularly tricky due to variations of criteria used to define hemodynamically significant PDA and multiple treatment protocols used with variations in dosing & route of administration (enteral vs IV bolus vs IV continuous) across different studies. A recent meta-analysis however concluded that high-dose oral ibuprofen was the most efficacious regimen for pharmacological closure of PDA. Because surgical ligation has become increasingly uncommon & published data is observational, it remains uncertain whether infants who fail pharmacological closure are more severely compromised to begin with, or in fact surgical intervention contributes to increased morbidity & mortality seen in such cases.