This study found that ranitidine use in very low birth weight newborns was associated with higher rates of infections, necrotizing enterocolitis (NEC), and mortality. Newborns treated with ranitidine had over 5 times higher risk of infections like sepsis and pneumonia compared to those not treated. Rates of NEC and mortality were also significantly higher in newborns receiving ranitidine. The study cautions against the use of ranitidine in preterm newborns due to these risks of severe infectious diseases and fatal outcomes.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
Antibacterial therapy in COVID-19 patients - an evidence based guidelineDr Jay Prakash
Overuse of antibiotics, delivery of tests and procedures that have little or no clinical benefit is a huge problem in health care, and one that has gained much more attention over the past decade. But despite efforts to reduce overuse like Choosing Wisely, rates of low-value care have barely budged.
COVID-19 affects different people in different ways. Information about the virus and COVID-19 continues to accrue, and interim guidance by multiple organizations is constantly being updated and expanded.
Point-of-Care Ultrasound Diagnosis an Asset for IBD PatientsJason Jaramillo
An MD practicing at the Maimonides Medical Center in New York, Dr. Jason Jaramillo is part of a community private practice. Jason Jaramillo, MD, provides patient-centered ultrasound diagnostics through the handheld, bedside, Point-of-Care Ultrasound (POCUS) approach.
As reported in Gastroenterology & Endoscopy News, a 2021 University of Calgary study revealed the effectiveness of bedside POCUS in delivering meaningful, efficient care to inflammatory bowel disease (IBD) patients. The impetus was the COVID-19 pandemic and a need to restrict IBD patients’ routine endoscopy access, as well as hospitalization and visits to the emergency department.
Calgary physicians developed a centralized bedside intestinal ultrasound protocol that enabled them to accurately and objectively measure IBD progress in patients. Of the 72 patients evaluated as part of the study, more than 84 percent underwent intestinal ultrasound, sigmoidoscopy, or a combination of the two techniques, which led to detection of active inflammation and significant management changes.
Physicians referred a half dozen of these patents to colorectal surgery for complicated disease resection, and three new IBD diagnoses were made as well. With POCUS diagnosis in place, not a single IBD visited the ER across the duration of the study. In addition, 80 percent of patients avoided acute care in-hospital endoscopy. These results point to POCUS as a significant asset to gastroenterologists seeking to minimize patient time in ER and clinical settings.
Antibacterial therapy in COVID-19 patients - an evidence based guidelineDr Jay Prakash
Overuse of antibiotics, delivery of tests and procedures that have little or no clinical benefit is a huge problem in health care, and one that has gained much more attention over the past decade. But despite efforts to reduce overuse like Choosing Wisely, rates of low-value care have barely budged.
COVID-19 affects different people in different ways. Information about the virus and COVID-19 continues to accrue, and interim guidance by multiple organizations is constantly being updated and expanded.
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...WAidid
«The first cause of recurrent infections in children is... childhood itself.» (J. Gary Wheeler)
Is it possibe to treat and prevent recurrent respiratory infections (RTIs) in pediatric age? Some studies have shown that immunostimulants/immunomodulators can reduce and prevent RTIs in children.
To learn more please visit www.waidid.org
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Norhayati Mokhtar, Public Health Physician at the Vector Borne Disease Sector, Disease Control Division, Ministry of Health Malaysia
#dengue #WorldNTDDay #BeatNTDs
Doctor's Data Inc GI Pathogen Reference GuideBonnieReynolds4
Doctor's Data Inc. GI Pathogen Profile, using the FilmArray multiplex PCR system, tests for 22 Viruses, parasites, and
bacteria, and offers new opportunities for the rapid, accurate diagnosis and prompt treatment of diarrheal
illnesses which may improve patient outcomes and clinical success.
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Fazlina Binti Mohamed Yusoff, Family Medicine Specialist at Klinik Kesihatan (Health Clinic) Anika, Klang, Selangor, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH
Speaker: Dr. Richard Lim Boon Leong is a Consultant Palliative Medicine Physician and Head of Palliative Care Unit, Selayang Hospital, Ministry of Health Malaysia.
Generic Zantac for Treatment of Duodenal and Gastric UlcersThe Swiss Pharmacy
Generic Zantac (Zinetac Tablets) is used in treatment of peptic ulcers (gastric and duodenal ulcers), gastroesophageal reflux disease (GERD), Zollinger-Ellison syndrome and scleroderma oesophagitis and to prevent duodenal ulcers and reflux disease from recurring.
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...WAidid
«The first cause of recurrent infections in children is... childhood itself.» (J. Gary Wheeler)
Is it possibe to treat and prevent recurrent respiratory infections (RTIs) in pediatric age? Some studies have shown that immunostimulants/immunomodulators can reduce and prevent RTIs in children.
To learn more please visit www.waidid.org
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Norhayati Mokhtar, Public Health Physician at the Vector Borne Disease Sector, Disease Control Division, Ministry of Health Malaysia
#dengue #WorldNTDDay #BeatNTDs
Doctor's Data Inc GI Pathogen Reference GuideBonnieReynolds4
Doctor's Data Inc. GI Pathogen Profile, using the FilmArray multiplex PCR system, tests for 22 Viruses, parasites, and
bacteria, and offers new opportunities for the rapid, accurate diagnosis and prompt treatment of diarrheal
illnesses which may improve patient outcomes and clinical success.
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Fazlina Binti Mohamed Yusoff, Family Medicine Specialist at Klinik Kesihatan (Health Clinic) Anika, Klang, Selangor, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH
Speaker: Dr. Richard Lim Boon Leong is a Consultant Palliative Medicine Physician and Head of Palliative Care Unit, Selayang Hospital, Ministry of Health Malaysia.
Generic Zantac for Treatment of Duodenal and Gastric UlcersThe Swiss Pharmacy
Generic Zantac (Zinetac Tablets) is used in treatment of peptic ulcers (gastric and duodenal ulcers), gastroesophageal reflux disease (GERD), Zollinger-Ellison syndrome and scleroderma oesophagitis and to prevent duodenal ulcers and reflux disease from recurring.
Generic zantac is an oral medicines used to treat stomach ulcer.Get more information on generic zantac here http://www.myhealthpharma.com/generic-zantac.aspx
Flagyl is used to treat bacterial infections of the vagina, stomach, skin, joints, and respiratory tract. This medication will not treat a vaginal yeast infection.
H2 RECEPTOR ANTAGONISTS
The H2 receptor antagonists (H2RA) are a class of drugs used to block the action of histamine on parietal cells (specifically the histamine H2 receptors) in the stomach, decreasing the production of acid by these cells.
PROTON - PUMP INHIBITORS
Proton-pump inhibitors (PPIs): are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production.
They are the most potent inhibitors of acid secretion available.
These drugs are among the most widely sold drugs in the world, and are generally considered effective.
The vast majority of these drugs are benzimidazole derivatives, but promising new research indicates the imidazopyridine derivatives may be a more effective means of treatment.
Pharmaceutical Quality Management of Dexamethasone tablets BP
Dexamethasone tablets USP
DEXAMETHSONE OPTHALMIC SUSPENSION BP
DEXAMETHSONE OPTHALMIC SUSPENSION USP
Dexamethasone is a synthetic (man-made) corticosteroid.
Corticosteroids are naturally-occurring chemicals produced by the adrenal glands located above the kidneys.
DISPERCAM, Marketing Plan for 2011
Markeiting & IMC plan for pharmaceutical product. using modern and emotional communication concept can be used for direct marketing by medical reps.
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Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
A randomised, double-blind clinical trial was undertaken in order to assess the effectiveness of probiotics in
the prevention of necrotising enterocolitis (NEC) in newborns weighing <1500 g.
A Comparative Study of the Efficacy of 5 Days and 14 Days Ceftriaxone Therapy...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Effects of moderate doses of vitamin A as an adjunct to the treatment of pneu...ISAMI1
Effects of moderate doses of vitamin A as an adjunct to the treatment of pneumonia in underweight and normal-weight children: a randomized, double-blind, placebo-controlled trial
How to improve enteral feeding tolerance in chronically critically ill patientsDr Jay Prakash
These interruptions to EN result in significant daily and cumulative calorie deficits, thus contributing to underfeeding and malnutrition. Underfed patients have an increased risk of all-cause mortality, bloodstream infections and longer ICU and hospital stays.
Bacteriological profile of childhood sepsis at a tertiary health centre in so...QUESTJOURNAL
Introduction: Sepsis is a leading cause of morbidity and mortality in children worldwide, even more so in developing countries. Knowledge of common pathogens and their antibiotic susceptibility pattern is useful for guiding initial treatment while awaiting blood culture results. Objective:To determine the major causative organisms and their antibiotic sensitivity pattern of childhood sepsis at the Niger Delta University TeachingHospital (NDUTH), with the aim of revising existing treatment protocols. Methods: Within a 2 year period (1st January 2014 to 31st December 2015) blood culture results of children with clinical suspicion of sepsis were retrospectively studied. Results:During the study period, 116 (12.11%) of the 958 children admitted into the Children Emergency Ward had blood culture tests. Thirty one (26.72%) had positive blood cultures.Eighteen (58.06%) of the organisms were gram positive while thirteen (41.93%) were gram negative. The predominant organism was Staphylococcus aureus in 16 (51.61%) followed by Klebsiella pneumoniae in 5 (16.13%) patients. The bacterial isolates demonstrated the highest sensitivity to the quinolones. Conclusion:There is need for periodic surveillance of the causative organisms and antibiotic susceptibility pattern of childhood sepsis to guide effective management of patients.
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263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. What’s Known On This Subject:
Acid-suppressive drugs could facilitate the onset of
infections in adults and children. Evidence for efficacy
is weak in newborns, esp. if preterm.
What This Study Adds:
First prospective study demonstrating an association
between the use of ranitidine and infections, NEC, and
fatal outcome in VLBW newborns. Caution is
advocated in using ranitidine in newborns.
3. Introduction
Infections are a common cause of morbidity and
mortality in premature infants.
Gastric juice is a major nonimmune defense
mechanism against infections.
Treatment with inhibitors of gastric acid secretion
leads to insufficient elimination of several ingested
pathogens.
Many studies show that these drugs facilitate the onset
of infections in adults and children.
4. There is evidence of an increased risk of infections and
NEC related to the use of histamine-2 receptor (H2-R)
blockers and proton pump inhibitors in neonates.
Not approved by the US FDA for use in neonates
because of the perceived safety and potential benefit.
Most common indications: prophylaxis or therapy of
stress ulcers and GERD,
Efficacy in preterm infants is still debated.
5. Methods
Populations
Birth weight (between 401 and 1500 g) /gestational age
(between 24 and 32 weeks)
From January 2006 to June 2007.
Exclusion criteria =immunodeficiency, malformations,
evidence of infections or NEC before enrollment, critical
conditions (blood pH < 6.8, or hypoxia with persistent
bradycardia for at least 1 hour), ranitidine therapy for fewer
than 7 days, and hospitalization for fewer than 8 weeks.
Indications, dosage, and duration of ranitidine treatment
were decided by the caregivers, who were unaware of the
study aims.
Approved by the Ethics Committee. Written consent was
obtained from the parents.
6. Outcome Measures
Primary outcome= the rate of infections in newborns
exposed or not exposed to ranitidine treatment.
Secondary outcomes=occurrence of NEC (Bell stage
>II), mortality, and duration of hospital stay.
7. •Sepsis = presence of signs suggestive of infection
associated with a positive blood culture.
•Pneumonia =presence of clinical signs (progressive
increase in oxygen requirement, bradycardia, and/or
apnea, tachypnea, or dyspnea) associated with positive
culture of endotracheal aspirate (when patients were
intubated) and with pathologic signs at chest
examination and radiograph.
•Urinary tract infections (UTI) =when a positive urine
culture together with clinical findings, such as sign of
sepsis, weight loss, or growth retardation were
present. Diagnosis of NEC and Bell stage were decided on
the basis of standardized clinical and radiologic criteria.
8. Data Collection
Researchers enrolled are unaware of the study aims.
Collected data’s : GA, BW, Apgar score, CRIB score,
occurrence of infections or NEC, antibiotic therapy,
indications for and dosage of ranitidine treatment,
duration of ranitidine treatment, modality and
duration of mechanical ventilation, oxygen therapy,
presence and duration of central vascular access, IVH,
PDA, time to reach full enteral feeding; results of
microbiological, radiologic, and laboratory tests;
diagnosis of stress-induced peptic disease and of
GERD, time to discharge, or death.
9. •Enteral feeding started on day 1 of life at 10 mL/kg per
day in 8 to 12 feeds, using preterm formula in all stable
infants.
•Maternal unfortified milk was given when available.
•Aspirate residue and abdominal circumference were
measured before each feed.
•In absence of food intolerance during the previous 24
hours, the total amount of enteral nutrition was
increased by 10 to 20 mL/kg per day.
10. • Enteral nutrition was discontinued if erythematic
abdominal wall, absence of bowel sounds, or blood in
the stools or in aspirates, associated with radiologic
markers of NEC-Bell stage higher than I were noted.
• Parenteral nutrition given through a central vascular
access in infants to maintain an adequate intake of
fluids, electrolytes, and nutrients, until full enteral
feeding (120 kcal/kg per day) was reached.
• Fluids were started at 70 to 100 mL/kg per day with
increments of 10 to 20 mL/kg per day until 150 to 180
mL/kg per day.
11.
12.
13. Statistics
Minimum sample size of 90 patients for each group to obtain a
power of the study of 90% (type 1 error = 0.05 with a 2-tailed test).
The Kolmogorov-Smirnov test was used to determine whether
variables were normally distributed. For continuous variables,
groups were compared using the t test, and the MannWhitney U test.
The χ2 test and Fisher’s exact test were used for categorical
variables.
The McNemar test was used to detect differences before and after
the use of ranitidine.
A multivariate analysis using binary logistic regression analysis
to evaluate whether GA, BW, sex, Apgar score, CRIB score, IVH,
PDA, central vascular access, or mechanical ventilation affected
the prescription of ranitidine.
Statistical analysis was performed by using SPSS, version 16.0 for
Windows (SPSS Inc., Chicago, IL).
14.
15. Results
Total enrolled=309 VLBW newborns.
35 infants were excluded because of critical clinical
conditions (10 patients), malformations (8 patients),
sepsis before enrollment (12 patients), and length of
hospitalization fewer than 8 weeks (5 patients).
Obtained data from 274 infants. 91 of these infants
had received ranitidine (42 as prophylaxis of stressinduced peptic disease; 49 because of suspected
GERD), and 183 represented the control cohort of
newborns not exposed to ranitidine.
16. The diagnosis of GERD was made based on clinical
criteria without pH-metry or endoscopy.
The characteristics did not differ between patients
receiving ranitidine for prophylaxis of stress-induced
peptic disease and patients receiving ranitidine for
GERD.
17. Multivariate binary logistic regression analysis revealed that the prescription of
ranitidine by physicians was not affected by
features
OR
CI
P
GA
0.846
0.694-1.031
0.098
BW
0.999
0.997–1.001
0.444
Sex
2.031
0.972–4.243,
0.060
Apgar score
1 minute: 0.863,
5 minute: 0.905,
1 minute: 0.653–
1.141, 5 minute:
0.486–1.687
1 minute:.301
5 minute:0.754
CRIB Score
1.008
0.869–1.169
0.918
IVH
2.127
0.635–7.124
0.221
PDA
0.755
0.323–1.764
0 .516
Central vascular
access
1.004
0.960–1.050
0 .855
Mechanical
ventilation
0.940
0.850–1.040
0.233
mechanical ventilation (OR 0.940, 95% CI 0.850–1.040, P = .233).
18. 309 cases
35 cases excluded
274 cases
91 cases
(received Ranitidine)
183 cases
(control cohort not exposed
to ranitidine)
19. Newborns treated with ranitidine had more infections
(OR 5.5, 95% CI 2.9–10.4, P < .001), i.e sepsis,
pneumonia, and UTI, than newborns not treated with
ranitidine.
Mean time to infection after starting ranitidine
treatment :17.9 days (95% CI 13.0–22.8).
In Infants treated with ranitidine, there was a slight
but not significant increase in drug dosage in subjects
presenting infections (intravenous 2.43 mg/kg per day,
95% CI 1.84–3.03 vs 1.85 mg/kg per day; 95% CI 1.55–
2.16, P = .052; enteral route 11.44 mg/kg per day; 95% CI
8.08–14.80 vs 9.82 mg/kg per day; 95% CI 8.22–11.42, P =
.310).
20. Risk of infections was unrelated to the duration of
ranitidine treatment. NEC was (P = .003) more frequent
(OR 6.6; 95% CI 1.7–25.0) in VLBW infants treated with
ranitidine (9.8%) than in those not exposed (1.6%).
Risk of NEC was unrelated to the dosage or duration of
ranitidine therapy. Twelve patients died during the
study.
Mortality rate -significantly higher in newborns
receiving ranitidine (9.9% vs 1.6%, P = .003), and
hospitalization was significantly longer in those
exposed to ranitidine (median 52 days, range 43 vs 36
days, range 22, P < .001).
21. Discussion
Graham et al, in a RCT of the effects of hand hygiene
practices on hospital-acquired late-onset gram-negative
sepsis, showed that the inhibitors of gastric acid secretion
entailed an increased risk of infection in LBW newborns.
In this study, the prescription of ranitidine was not
influenced by the severity of the patient’s clinical
condition.
Bianconi et al reported an association between ranitidine
use and the risk of late-onset sepsis, but they used a
retrospective design and the number of newborns enrolled
was very small.
22. In a RCT, Stoll et al evaluated the relationship between
postnatal steroid exposure and late-onset sepsis in
VLBW infants. They observed that treatment with
dexamethasone was associated with an increased risk
of sepsis and meningitis.
During the analysis of the factors, the authors found
an increased use of H2R blocker therapy in patients
developing infections.
In a prospective study, Beck-Sague et al reported a
fourfold increase in the risk of bloodstream infection
in neonates who received H2R blockers; in this case,
neonates who developed infection were more severely
ill and were of lower GA on admission than infants not
developing these infections.
23. Gastric juice and intestinal microflora : major defense
factors against invasion of the gut by microorganisms.
Gastric juice kills bacteria within 15 minutes when the
pH is < 3.0.
Changes in the composition of the intestinal
microflora are associated with the development of
sepsis and NEC. Thus, it is conceivable that
hypochlorhydria could contribute to the abnormal
immune activation observed during NEC.
The direct effect exerted by ranitidine on the immune
system could influence the risk for NEC in neonates.
Activation of H2R alters the production of
inflammatory cytokines and disrupts the Th1–Th2
balance, thereby leading to insufficient control of
infections and inflammation at the intestinal level.
24. There is no clear evidence that H2R blockers are beneficial in
many clinical conditions typical of neonatal age, such as apnea.
The results suggest that
Ranitidine to be administered after a careful consideration of
the
risk-benefit ratio.
An increased mortality in newborns receiving ranitidine.
Mortality in ranitidine exposed group was 6 times higher
This suggests that caution should be exercised regarding the
administration of ranitidine
The administration of ranitidine in VLBW infants increases
health care costs due to prolonged hospital care.
The median cost of hospitalization is about $1250 per day for a
VLBW infant. The difference in median duration of
hospitalization between the 2 groups was 20 days, thereby
resulting in a reduction of about $25 000 per patient.
25. Conclusion
Ranitidine should be administered with care in
preterm infants because of the risk of severe infectious
disease, NEC, and fatal outcome.
Further studies are necessary to investigate the
pathogenesis of these effects and the possible
prophylactic measures that could be taken to prevent
them.