Risk factors of congenital heart disease in newborn: evaluation of pulse oximetry as a screening tool

Congenital heart disease [CHD] represents a common neonatal condition that would be ideally suited to a screening program if simple and reliable methods were available. The aim of this study was to throw a light on the risk factors of congenital heart disease among newborn infants and to evaluate the validity and accuracy of pulse oximetry as a screening tool for congenital heart disease among them. This was a case control study carried out in the Pediatric Department of Gharian teaching hospital over two years period from January 2006 to January 2008 and included 476 neonates, classified into two groups: Study group: included 176 newborn infants properly diagnosed as having congenital heart disease, and control group: included 300 healthy newborn infants free from any congenital defects and randomly selected from hospital discharge of maternity and neonatal care unit and properly matched with the study group regarding age of newborn, birth order and parental education. All newborns included in the study were subjected to: full history taking through questionnaire interview, complete neonatal examination, Pulse oximetry measurement on the right hand of the infant and on either foot, plain x ray chest and heart, ECG and Echocardiography. The results of this study revealed that Congenital heart diseases in newborns are significantly associated with, Prematurity [OR,2.8; 95% CI: 1.6-4.8, P< 0.001], male sex [OR, 2.39; 95% CI:1.6-3.5, P< 0.05], low birth weight <2.5kg [OR, 3.3; 95% CI: 1.9 -5 .6, P< 0.001],older mothers >/= 35 years [OR, 3.8; 95% CI: 2.6-5.7,P< 0.001], older fathers >/= 40 years [OR, 3.812; 95% CI:2.12-4.59,P<0.001], And also to some maternal, gynaecological and obstetric risk factors such as, previous stillbirth delivery [OR, 4.8; 95% CI:2.7-8.5,P<0.001], previous abortions [OR,3.7; 95% CI: 2.07-6.5, P< 0.001], positive family history of CHD in a first-degree relative [OR:2.5; 95% CI:0.94-6.7,P<0.05], maternal diabetes mellitus during the current pregnancy [OR: 2.6; 95% CI: l.5-4.6,p<0.001], lack of folic acid supplementation during current pregnancy [OR,2.5; 95% CI:1.7-3.8,P< 0.001], maternal smoking [OR,8.4; 95% CI:3.1-22.7,P< 0.01], paternal smoking [OR, 2.4; 95% CI: 1.7-3.6, P< 0.001] and maternal obesity BMI >/= 30 [OR, 4.8; 95% CI: 3.1-7.4,P< 0.001]. Clinical examination alone to detect congenital heart disease in newborns had sensitivity of 94.3% and specificity of 93%, Post ductal pulse oximetry screening for CHD on either foot [saturation <95%] had sensitivity of 69.9% and specificity of 87%, but still gave 30.1% false-negative patients, all with aortic arch obstruction, however, better validity was obtained by pulse oximetry screening, on adding one further criterion: saturation <95% in both hand and foot or a difference of >/= 3% between hand and foot, with, a sensitivity of 97.16%, specificity of 96.0%, positive predictive value of 93.44% and negative predictive value of 98.3%. The combined use of Pulse oximetry and clinical examination as a screening tool for CHD among newborn infants showed a sensitivity 99.4%, specificity 99%, positive predictive value 98.3%, negative predictive value 99.7%., false negative percentage 0.6% and the false positive percentage 1.0%. It is concluded from this study that congenital heart diseases in newborns are significantly associated with, Prematurity, male sex, low birth weight, older mothers >35 years, older fathers >/= 40 years, and also to some maternal, gynaecological and obstetric risk factors such as, previous stillbirth delivery, previous abortion, positive family history of CHD in a first-degree relative, maternal diabetes mellitus during the current pregnancy, lack of folic acid supplementation, parental smoking and maternal obesity. Pre and post ductal pulse-oximetry screening offers an effective, accurate and valid screening tool for detecting CHD in newborn infants with higher sensitivity and specificity, particularly if combined with clinical examination. It can enhance the clinician's ability to detect life-threatening CHD: This screening method should become a part of the discharge plan for every newborn. Large scale prospective studies are needed to assess its validity with higher precision

Iatrogenic illness in pediatric intensive care unit at Gharian Teaching Hospital- Libya

The primary goal of intensive care is to prevent mortality in patients with reversible critical illness. latrogenic illness can increase the morbidity or the mortality of hospitalized patients in Paediatric Intensive Care Units [PICUs]. Studying this illness is an indicator to improve quality of care. The aim of this prospective follow up study was to determine the incidence and risk factors of iatrogenic illness together with the outcome among cases admitted to the Paediatric Intensive Care Unit [PICU] of Gharian Teaching Hospital in an attempt to prevent or minimize such illness. This study included all consecutive admissions of patients over a 1 year period from January 2006 to January 2007 in PICU of Gharian teaching hospital and included 423 patients. The results of this study revealed that the incidence of iatrogenic illness among admitted cases was 22.93%, where human errors represented 18.44% and mechanical errors represented 4.49% among them. Higher incidence of iatrogenic illness was observed with: younger age infants [below 2 years] 27.55% [RR=2.22, CI=1.35-3.64, P<0.001], longer duration of stay [one week or more] 26.83% [RR=2.83, CI=1.48-5.41, P<0.001], increased bed occupancy rate> 3/5 [60%] 33.3% [RR=2.26, CI=1.56- 3.25, P<0.001], in the presence of respiratory diseases 34.45% [RR=1.87, CI=1.32- 2.63] [P < 0.001], with the use of mechanical ventilation 54.54% [R=2.57, CI=1.68-3.94, P<0.001], with high PRISM score [>/= 30] 48.72% [RR=2.85, CI=2.05- 3.94, P< 0.001]. Regarding the outcome, mortality rate was [7.57%] among the total number of studied cases, and higher mortality rates were observed among: infants below 2 years [9.86%], cases suffering from respiratory disorders [14.29%], patients stayed more than one week in PICU [9.15%], cases with bed occupancy rate more than 3/5 [11.83%], cases with PRISM score >/= 30 [25.64%], cases suffering from iatrogenic illness [13.4%] and also among artificially ventilated cases [81.81%]. There was a significant correlation between iatrogenic illness and: PRISM score [r=0.6817, P<0.001], the use of mechanical ventilation [r=0.5324, P<0.001], bed occupancy rate [r=0.5181, P<0.001], the presence of respiratory disease [r=0.4631, P<0.001], duration of stay in PICU [r=0.4432, P<0.01], and age [r=-0.3813, P<0.01]. Also mortality outcome was significantly correlated to: PRISM score [r=0.8734, P<0.001], the use of mechanical ventilation [r=0.7623, P<0.001], the presence of iatrogenic illness [r=0.3972, P<0.01], severity of iatrogenic complication [r=0.5481, P<0.001], the presence of respiratory disease [r=0.3.671, P<0.01], duration of stay in PICU [r=0.5194, P<0.001], bed occupancy rate [r=0.4785, P<0.001] and age [r=-0.4126, P<0.01]. It is concluded from this study that iiatrogenic complications represent a real problem in paediatric intensive care unit [PICU] with an incidence rate of [22.93%] among admitted cases. Human errors followed by machine defects were the most common causes of iatrogenic complications. Mortality outcome rate was [7.57%] and PRISM score was a good predictor of high risk cases in PICU. Mortality outcome in PICU is significantly correlated to the occurrence and to the severity of iatrogenic illness and each of the mortality outcome and the occurrence of iatrogcnic illness was significantly associated with: higher PRISM score, the use of mechanical ventilation, increased bed occupancy rate, the presence of respiratory disease, prolonged duration of stay in PICU, and younger age of children. Increasing the number of beds in PICU, improving the quantity and quality of man power with continuous supervision and proper training of them, together with the frequent examination and assessment of patients by using PRISM score to detect high risk ones is recommended to minimize iatrogenic complications and to improve the outcome in PICU

Effect of combined desferal/ defriprone therapy on iron overload in beta thalassemic children

Management of B-thalassemia major with regular blood transfusion and iron chelation therapy with desferrioxamine [DFO] has markedly improved the prognosis of the disease but some patients continue to develop iron-related complications and to die despite the use of DFO. Deferiprone [DFP] is suggested to be the most promising oral iron chelator under development. The present study was conducted on 60 pediatric patients with Beta-thalassemia major to evaluate the effectiveness of combined therapy with DFO and DFP compared to DFO therapy alone. The patients were evaluated clinically with complete history taking, routine laboratory investigations, doppler echocardiography, serum ferritin and serum cardiac troponin T [cTnT] estimation. The results showed significant improvement in hemodynamic parameters and significant decrease in serum cTnT and decrease in serum ferritin post-treatment with DFO and combined DFO/DFP when compared with pre-treatment values of the patients. Combination therapy was more effective than DFO therapy alone in the improvement of hemodynamic parameters, reduction of the myocardial damage indicator [cTnT] and reduction of serum ferritin. The authors recommend the use of combined DFO/DFP therapy in the management of transfusional iron overload in beta-thalassemia major