Evidence-Based Guidelines for the Management of Allergic Bronchopulmonary Aspergillosis (ABPA) in Children and Adolescents with Asthma.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) frequently complicates asthma. There is urgent need to develop evidence-based guidelines for the management of ABPA in children. The Evidence Based Guideline Development Group (EBGDG) of the Indian Academy of Pediatrics (IAP) National Respiratory Chapter (NRC) addressed this need. METHODS: The EBGDG shortlisted clinical questions relevant to the management of ABPA in asthma. For each question, the EBGDG undertook a systematic, step-wise evidence search for existing guidelines, followed by systematic reviews, followed by primary research studies. The evidence was collated, critically appraised, and synthesized. The EBGDG worked through the Evidence to Decision (EtD) framework, to formulate recommendations, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Seven clinical questions were prioritized, and the following recommendations formulated. (1) Children with poorly controlled asthma should be investigated for ABPA (conditional recommendation, moderate certainty of evidence). (2) Low dose steroid therapy regimen (0.5 mg/kg/d for the first 2 wk, followed by a progressive tapering) is preferable to higher dose regimens (conditional recommendation, very low certainty of evidence). (3) Oral steroid regimens longer than 16 wk (including tapering), should not be used (conditional recommendation, very low certainty of evidence). (4) Antifungals may or may not be added to steroid therapy as the evidence was neither in favour nor against (conditional recommendation, low certainty of evidence). (5) For clinicians using antifungal agents, the EBGDG recommends against using voriconazole instead of itraconazole (conditional recommendation, very low certainty of evidence). (6) No evidence-based recommendation could be framed for using pulse steroid therapy in preference to conventional steroid therapy. (7) Immunotherapy with biologicals including omalizumab or dupilumab is not recommended (conditional recommendation, very low certainty of evidence). CONCLUSIONS: This evidence-based guideline can be used by healthcare providers in diverse clinical settings.

Successful management of a broken epidural catheter!!!

Breakage of epidural catheter though rare is a well-known but worrisome complication. Visualization of retained catheter is difficult even with modern radiological imaging techniques, and active surgical intervention might be necessary for removal of catheter fragment. We report such a case of breakage of an epidural catheter during its removal which led to surgical intervention.

Role of paracetamol in treatment of childhood Fever: a double-blind randomized placebo controlled trial.

OBJECTIVE: To investigate whether paracetamol administration (i) increases the overall duration of fever; and (ii) is effective and safe, in symptomatic treatment of febrile children. DESIGN: Randomized double blind placebo controlled trial. METHODS: The trial was conducted at a tertiary care setting. 210 febrile children (6 months - 6 years) with uncomplicated respiratory tract infection received oral paracetamol (15 mg/kg) or placebo, if axillary temperature was 37.6C. Outcome measures included fever clearance time, rate of fall of temperature, percent reduction of temperature, proportion of afebrile children, symptomatic improvement (based on categorical improvement in activity, alertness mood, comfort, appetite and fluid intake) and clinical and biochemical adverse effects. RESULTS: Fever clearance time [median (SE, 95% CI)] was comparable between the two groups [paracetamol: 32 (2, 22-37) h; placebo: 36 (1, 33-39) h; P = 0.23]. Paracetamol resulted in significantly higher rate of fall of temperature (paracetamol: 0.33 +/-; 0.16 degrees C/h; placebo 0.07 +/- 0.13 degrees C/h: P <0.001), and percentage reduction of temperature (paracetamol: 85.4 +/- 22.4; placebo 45.5 +/- 34.1; mean difference 39.9; 95% CI 31.9-47.9; P<0.001) during first four hours after drug administration. Proportion of afebrile children after 4 hours (paracetamol: 46.6%; placebo: 12.1%; P <0.001) and symptomatic improvement at 6 hours were significantly higher (P<0.001) after administration of paracetamol as compared to placebo. No serious clinical or biochemical adverse drug effects were observed. CONCLUSIONS: Paracetamol achieves effective antipyresis and provides early symptomatic improvement in children with febrile illness without prolongation of fever duration or excessive adverse effects.