Search

Acute exacerbations of Cystic Fibrosis (AECF) are associated with significant morbidity. Recommendations are to treat for 2-3 weeks despite limited data. Spirometry is a measure of clinical response yet appears to plateau at 7-10 days. While durations9 days have been associated with poorer outcomes, a duration of 10 days may be as effective as 14 days, potentially conferring advantages in terms of cost and adverse events. A 2019 Cochrane review by Abbott et al. did not identify any randomised controlled trials (RCT) comparing durations of treatment. Utilising data from non-randomised studies (NRS), we report a systematic review of intravenous antibiotic treatment, exploring changes in FEVSystematic review of published literature following a search of MEDLINE, Embase, CINAHL and the Cochrane Clinical Trials register. Guidelines from the Preferred Reporting items for Systematic reviews and Meta-Analysis (PRISMA) and reporting Meta-analysis of Observational studies (MOOSE) statement were followed.No randomised controlled trials were identified that specifically examined duration of treatment during AECF. This study included all relevant RCTs and also NRS, grouping according to study characteristics, such as length of treatment, location, year, and also characteristics of the patient population. 52 studies, comprising 79 subgroups, and 1,597 patients, were identified. Mean change (95%CI) in ppFEVThis systematic review provides evidence that shorter durations of treatment may be associated with similar changes in FEV

Item does not contain fulltext OBJECTIVE: To assess the impact of milrinone administration on time spent on nitric oxide (iNO) in infants with acute pulmonary hypertension (aPH). We hypothesized that intravenous milrinone used in conjunction with iNO would reduce the time on iNO therapy and the time spent on invasive ventilation in infants ≥34 weeks gestation with a diagnosis of aPH. We aimed to assess the practicality of instituting the protocol and contributing to a sample size calculation for a definitive multicentre study. STUDY DESIGN: This was a multicentre, randomized, double-blind, two arm pilot study, with a balanced (1:1) allocation. Infants with a gestation ≥34 weeks and a birth weight ≥2000 grams aPH, an oxygenation index of ≥10, and commenced on iNO were eligible. Participants on iNO were assigned to either a milrinone infusion (intervention) or a normal saline infusion (placebo) for up to 35 h. The primary outcome was time on iNO and feasibility of conducting the protocol. RESULTS: The trial was terminated early after 4 years of enrollment due to poor recruitment. Four infants were allocated to the intervention arm and 5 to the placebo arm. The groups were well matched for baseline variables. No differences were seen in any of the primary or secondary outcomes. CONCLUSION: Conducting an interventional trial in the setting of acute pulmonary hypertension in infants is not feasible using our current approach. Future studies in this area require alternative trial design to improve recruitment as this topic remains understudied in the neonatal field. TRIAL REGISTRATION: www.isrctn.com ; ISRCTN:12949496; EudraCT Number:2014-002988-16. 01 februari 2023

A post hoc appraisal of the PDA RCT to assess the relationship between early patent ductus arteriosus (PDA) shunt elimination and chronic lung disease or death (CLD/Death). Infants 0.05). A persistent PDA beyond Day 8 was associated with CLD/Death (aOR 6.5 [1.7–25.5]). Early shunt elimination in preterm infants with a PDA may reduce respiratory morbidity when compared to infants with prolonged shunt exposure.

Background and Aims: Infants born to mothers with gestational diabetes mellitus (GDM) have impaired myocardial performance and are at risk of pulmonary hypertension. We aimed to assess myocardial deformation and left ventricular (LV) rotational mechanics in this population. Methods: We studied 40 infants of mothers with GDM and 40 control infants. Three echocardiograms were carried out over the first 3 days after birth. Results: GDM infants had a lower gestation at birth and a thicker septal wall, a higher LV eccentricity index (indicating septal bowing), and a lower PAATi (indicating higher pulmonary vascular resistance) (all p < 0.05). GDM infants had lower LV strain, systolic and early diastolic strain rates, lower right ventricular (RV) strain, and early diastolic strain rates over the study period (all p < 0.05). By day 3, GDM infants had higher twist, torsion, and higher LV twist and untwist rates (all p < 0.05). GDM status was an independent predictor of LV and RV function and pulmonary vascular resistance (p < 0.01). Conclusion: Infants of mothers with GDM demonstrate important changes in myocardial function in addition to pulmonary vascular resistance that do not resolve by hospital discharge. The observed LV twist increase in GDM infants may be a compensatory mechanism for the lower longitudinal function in this cohort.

Down Syndrome (DS) is the most common chromosomal abnormality of live born babies. Individuals with DS are at increased risk of cardiopulmonary morbidities in the early neonatal period, infancy and childhood that manifest with elevated pulmonary arterial pressures and altered myocardial performance. Pulmonary hypertension (PH) during the early neonatal period remains under-recognised in this population. PH may occur with or without a congenital heart defect in children with DS and is more common than in the general population. Early detection and continued screening of PH throughout infancy and childhood for these at-risk children is crucial for prompt intervention and potential prevention of long-term sequelae on cardiac function. This review summarises the main physiological concepts behind the mechanisms of PH in children with DS and provides a summary of the current available literature on PH and its impact on myocardial performance.

There is a dearth of longitudinal data describing the evolution of cardiopulmonary hemodynamics in infants with Down syndrome (DS) beyond infancy. We hypothesized that babies with DS, independent of the presence of congenital heart disease (CHD), demonstrate biventricular systolic and diastolic impairment and sustained elevation of pulmonary pressures compared with controls over the first 2 years of age.This was a prospective observational cohort study of 70 infants with DS (48 with CHD and 22 without CHD) and 60 controls carried out in 3 tertiary neonatal intensive care units in Dublin, Ireland. Infants with DS with and without CHD and non-DS controls underwent serial echocardiograms at birth, 6 months, 1 year, and 2 years of age to assess biventricular systolic and diastolic function using deformation analysis. Pulmonary vascular resistance was assessed using pulmonary artery acceleration time and left ventricular (LV) eccentricity index.Infants with DS exhibited smaller LV (birth: 27 ± 4 vs 31 ± 2 mm, P lt; .01; 2 years: 43 ± 5 vs 48 ± 4 mm, P lt; .01) and right ventricular (birth: 28 ± 3 vs 31 ± 2 mm, P lt; .01; 2 years: 40 ± 4 vs 44 ± 3 mm, P lt; .01) lengths and lower LV (birth: -19% ± 3% vs -22% ± 2%, P lt; .01; 2 years: -24% ± 2% vs -26% ± 2%, P lt; .01) and right ventricular (birth: -19% ± 4% vs -22% ± 3%, P lt; .01; 2 years: -29% ± 6% vs -33% ± 4%, P lt; .01) systolic strain over the 2-year period. Pulmonary artery acceleration time was lower in the DS group throughout the study period (birth: 44 ± 10 vs 62 ± 14 ms, P lt; .01; 2 years 71 ± 12 vs 83 ± 11 ms, P lt; .01). No differences were observed between DS infants with and without CHD (all P gt; .05).Infants with DS exhibit impaired maturational changes in myocardial function and pulmonary vascular resistance. Such novel findings provide valuable insights into the pathophysiology affecting cardiorespiratory morbidity in this population.

Introduction: Infants with Down syndrome (DS)are at an increased risk of cardiopulmonary morbidity from birth. However, there is a dearth of information regarding longitudinal assessment of myocardial performance and pulmonary haemodynamics in infants with DS, both with and without structural cardiac disease, over the first two years of age.Hypothesis & Aim: Our study hypothesis was that babies with DS have both persistent myocardial impairment and develop pulmonary hypertension (PH)more frequently and to a more severe extent than their non-DS counterparts, independent of structural cardiac disease. The aim of this study was to serially assess left ventricular (LV) and right ventricular (RV) performance and measurements of pulmonary haemodynamics in babies with DS, with and without congenital heart disease (CHD), utilising advanced echocardiography techniques over the first two years of age and to compare those measurements to a cohort of non-DS controls.Methods: This was a prospective observational cohort study performed across the three tertiary neonatal units of Dublin. All infants with a diagnosis of DS made antenatally or postnatally were eligible for inclusion. Echocardiography was performed at six time points over the first two years of age for both the DS and control cohorts using novel echocardiography modalities including tissue Doppler imaging and speckle tracking echocardiography.Results: Seventy babies with DS and 60 control infants were enrolled. Forty-eight (69%) of infants with DS were born with CHD. There is sustained impairment of biventricular systolic and diastolic performance and indices of PH in infants with DS, irrespective of structural cardiac disease, compared to controls over the first two years of age. Conclusion: This work provides new insights into the evolution of LV and RV function and pulmonary haemodynamics in infants with DS over the first two years of age.

To assess the influence of diastolic dysfunction on the evolution of pulmonary hypertension in neonates with Down Syndrome over the early newborn period.This was a prospective observational cohort study. Echocardiography was performed three times over the first week of life in both Down syndrome and control cohorts. Measurements of pulmonary arterial pressure in addition to left ventricular (LV) and right ventricular systolic and diastolic function were collected.Seventy babies with Down syndrome and 60 control infants were enrolled. Forty-eight of the infants with Down syndrome (69%) were born with congenital heart disease (CHD). Echocardiography surrogates of pulmonary hypertension and myocardial function remained significantly impaired in the Down syndrome group in comparison with control infants (all P .01). In the Down syndrome group, LV early diastolic strain rate was independently associated with measures of pulmonary hypertension while controlling for gestational age, cesarean delivery, and the presence of CHD (P .01).Intrinsic LV diastolic impairment is directly associated with higher indices of pulmonary hypertension in infants with Down syndrome and may be a contributing factor to its evolution.

To examine the impact of PRBC transfusion on pulmonary vascular resistance (PVR), systemic vascular resistance and myocardial function using echocardiography and cerebral and splanchnic tissue oxygenation using near-infrared spectroscopy (NIRS) in premature babies with and without a PDA.A prospective observational study of premature infants born1500 g in receipt of PRBC transfusions beyond 10 days of age. Echocardiography and NIRS monitoring were performed at baseline, during the transfusion and 24 h after transfusion.Thirty infants with a median gestation of 26.4 [24.8-28.0] weeks were enrolled. Ten infants had a PDA. Following transfusion, a significant decrease in PVR markers occurred in all infants. Right ventricular (RV) function increased following transfusion in the PDA closed group only. Cerebral oxygen saturation increased following transfusion in all infants. Babies in the PDA open group had significantly lower splanchnic oxygen saturations at baseline compared to the PDA closed group which persisted over the study period and were unaltered by transfusion.PRBC transfusion lowers PVR irrespective of PDA status. Those with a PDA demonstrated a lack of improvement in RV function and splanchnic oxygenation highlighting the impact a PDA has on the neonatal circulation.The presence or absence of the PDA imposes differential effects on splanchnic oxygenation during red blood cell (PRBC) transfusion in the premature population. This is the first study to assess the impact of the PDA on splanchnic oxygenation via near-infrared spectroscopy (NIRS) during red blood cell transfusion in premature neonates. New insights have been found into the impact of PRBC transfusion on pulmonary vascular resistance, right ventricular function, cerebral and splanchnic oxygenation in the presence and absence of a PDA and emphasises the ongoing impact of ductal patency on gut oxygenation.

ObjectiveLeft ventricle (LV) rotational mechanics is an emerging tool to characterise LV function, but warrants further evaluation in neonates. The aim of this study was to compare LV rotational mechanics between term and extremely preterm babies over the first week of age.MethodsIn this prospective study, we serially assessed LV rotational parameters in 50 term infants and compared them with a historical dataset of 50 preterm infants born ResultsThere was no change in LV twist, LV torsion, basal rotation or apical rotation in term infants over the study period (all p>0.05). LV twist and torsion were higher in preterm infants, and increased over time. In preterm infants, basal rotation evolved from anticlockwise to clockwise rotation. Apical rotation remained anticlockwise in both groups (all p>0.05). LV twist rate (LVTR) and untwist rate was higher in preterm infants and increased over the three time points (all p>0.05). There was a strong positive correlation between LV torsion and LV untwist rate (LVUTR) in the entire cohort during the third scan.ConclusionTerm infants exhibit minimal LV twist which remains unchanged over the first week of age. This is in contrast to premature infants who demonstrate increasing indices of twist, torsion, LVTR and LVUTR over the first week, likely as a compensatory mechanism for reduced LV compliance.

IntroductionAlthough chronic pulmonary hypertension (cPH) secondary to chronic neonatal lung disease is associated with increased mortality and respiratory and neurodevelopmental morbidities, late diagnosis (typically ≥36 weeks postmenstrual age, PMA) and the use of qualitative echocardiographic diagnostic criterion (flat interventricular septum in systole) remain significant limitations in clinical care. Our objective in this study is to evaluate the utility of relevant quantitative echocardiographic indices to identify cPH in preterm neonates, early in postnatal course and to develop a diagnostic test based on the best combination of markers.Methods and analysisIn this ongoing international prospective multicentre observational diagnostic accuracy study, we aim to recruit 350 neonates born Ethics and disseminationEthics approval has been received by the Mount Sinai Hospital Research Ethics Board (REB) (#16-0111-E), Sunnybrook Health Sciences Centre REB (#228-2016), NHS Health Research Authority (IRAS 266498), University of Iowa Human Subjects Office/Institutional Review Board (201903736), Rotunda Hospital Research and Ethics Committee (REC-2019-008), and UBC Children’s and Women’s REB (H19-02738), and is under review at Boston Children’s Hospital Institutional Review Board. Study results will be disseminated to participating families in lay format, presented to the scientific community at paediatric and critical care conferences and published in relevant peer-reviewed journals.Trail registration numberNCT04402645.

A patent ductus arteriosus (PDA) in preterm infants is associated with increased ventilator dependence and chronic lung disease, necrotizing enterocolitis, intraventricular haemorrhage, and poor neurodevelopmental outcome. Randomised controlled trials of early PDA treatment have not established a drop in the aforementioned morbidities. Those trials did not physiologically categorise PDA severity. Incorporating the specific physiological features of a haemodynamic significant PDA may evolve our understanding of this phenomenon, allowing accurate triaging using echocardiography and targeted treatment. Our group has recently demonstrated that a PDA severity score (PDAsc) derived at 36-48 hours of age can accurately predict the later occurrence of chronic lung disease or death (CLD/Death). Using echocardiography, we assessed PDA characteristics, as well as left ventricular diastolic function and markers of pulmonary overcirculation, and from this formulated a PDAsc. Gestation was also incorporated into the score. We hypothesise that in preterm infants at high risk of developing CLD/Death based on a PDAsc, early treatment with Ibuprofen compared with placebo will result in a reduction in CLD/Death. This is a single centre double-blind two arm randomised controlled trial conducted in the neonatal intensive care unit in the Rotunda Hospital, Dublin. Echocardiogram is carried out in the first 36-48 hours of life to identify preterm infants with a PDAsc ≥ 5.0 and these infants are randomised to Ibuprofen or placebo. Primary outcomes are assessed at 36 weeks post menstrual age. This pilot study’s purpose is to assess the feasibility of performing the trial and to obtain preliminary data to calculate a sample size for a definitive multi-centre trial of early PDA treatment using a PDAsc. We aim to recruit a total of 60 infants with a high risk PDA over three years. Trial Registration: ISRCTN ISRCTN13281214 (26/07/2016) and the European Union Drug Regulating Authorities Clinical Trials Database 2015-004526-33 (03/12/2015).

Optimum management of the patent ductus arteriosus (PDA) in preterm infants remains one of the most debated topics within the field of neonatology. Despite numerous observational studies and over 60 randomized control trials, consensus on PDA management remains elusive. In order to make meaningful progress on the controversial issue of PDA management, several key factors must be thoroughly addressed; namely (1) accurate identification of infants at greatest risk of long-term morbidities from PDA exposure, (2) acceptance that the PDA is not a dichotomous entity and an individualised approach to its management is required for each neonate, (3) international consensus on what constitutes a haemodynamically significant PDA and (4) the incorporation of multi-organ assessment when evaluating the impact a PDA may pose on overall neonatal physiology. This review assesses the evidence base available supporting various therapeutic strategies for PDA, the deficits in our current knowledge on the definition of haemodynamic significance and future directions to pursue in order to more successfully address this contentious subject.

The association between the patent ductus arteriosus (PDA) and neonatal morbidity, mortality and poor neurodevelopmental outcome in later childhood has been the focus of intense debate for decades. The lack of evidence supporting therapeutic strategies aimed at achieving PDA closure has led to the widespread adoption of conservative management aimed at mitigating the impact of shunt volume without achieving ductal closure. In this article, we review this management approach, describe the supportive evidence and potential complications associated with this strategy.

Objective To evaluate the incidence of direct admission of infants with Down syndrome to the postnatal ward (well newborn nursery) vs the neonatal intensive care unit (NICU), and to describe the incidence of congenital heart disease (CHD) and pulmonary hypertension (PH). Study design This retrospective cohort study of Down syndrome used the maternal/infant database (2011-2016) at the Rotunda Hospital in Dublin, Ireland. Admission location, early neonatal morbidities, outcomes, and duration of stay were evaluated and regression analyses were conducted to identify risk factors associated with morbidity and mortality. Results Of the 121 infants with Down syndrome, 54 (45%) were initially admitted to the postnatal ward, but 38 (70%) were later admitted to the NICU. Low oxygen saturation profile was the most common cause for the initial and subsequent admission to the NICU. Sixty-six percent of the infants (80/121) had CHD, 34% (41/121) had PH, and 6% died. Risk factors independently associated with primary NICU admission included antenatal diagnosis of Down syndrome, presence of CHD, PH, and the need for ventilation. Conclusions Infants with Down syndrome initially admitted to the postnatal ward have a high likelihood of requiring NICU admission. Overall, high rates of neonatal morbidity were noted, including rates of PH that were higher than previously reported. Proper screening of all infants with Down syndrome for CHD and PH is recommended to facilitate timely diagnoses and potentially shorten the duration of the hospital stay.

Objectives The aim of this study was to quantify the rate of incidental findings identified on elective research echocardiography performed on neonates younger than 29 weeks’ gestation. Methods We conducted a retrospective study of echocardiographic examinations performed within the first 24 hours of age on neonates younger than 29 weeks’ gestation over a 3-year period for research purposes. Incidental echocardiographic findings and pertinent clinical data were recorded. Results Echocardiographic examinations performed on 145 neonates were retrospectively reviewed. Forty-three neonates (30%) had a total of 54 unexpected findings (37%). Most comprised malpositioned umbilical venous catheters, where the tip was located in the left atrium. The remainder of the conditions identified included unsuspected congenital heart disease, liver hematomas, and unexpected pulmonary hypertension. Conclusions There is a high rate of incidental findings identified on screening echocardiograms. Routine targeted neonatal echocardiographic screening of preterm neonates may be warranted to identify the considerable likelihood of asymptomatic findings.

Background Medical education is an evolving specialty. Educating the doctors of the tomorrow is investment in our own future and should capitalise on all available technologies. Education is more challenging in recent years due to the increased work load of doctors and increased number of students. It is recognised that students need to be prepared not only from a cognitive and clinical perspective, but also in the affective domain. Neonatology is a complex area, and students have limited background understanding of the specialty. Many different modalities of teaching have been trialled. The use of video in medical education dates back as far as 1960 (1), and students engage with video technology to enhance their learning experience (2). Video provides an opportunity to give a voice to parents and families which is not always available in clinical interactions. Aims We aim to assess the impact of video footage of parental NICU experiences on student attitudes towards prematurity. Methods We introduced video technology into our 2018 undergraduate education programme. Each student was asked to complete a 3 question ‘Classroom Assessment Techniques’ (CAT) questionnaire before and after watching a video. The video described the ‘parental experience’ of having an extremely premature infant. Results and Discussion The completion of the CAT before and after the video was feasible, and 100% response rate was obtained. Some students elected not to answer each question. After watching the video students had a greater appreciation for the possibility of morbidity and mortality for premature infants. The area that had the greatest impact on the students was the importance of explaining to the parents what they should expect after the baby is born. Parental anxiety featured strongly as an issue after watching the video. This is an important concept for medical students to grasp and a difficult one to communicate in didactic form. This understanding could improve communication with parents and may promote empathy for families dealing with illness across different specialties. Conclusion The significance of the patient/parent experience is a concept that is challenging to teach. Appreciating the impact neonatal illness has on both the patient and parent is essential. Providing students with insight into the consequences of prematurity will equip them with holistic skills that will be vital for their future practice. Video has a potential role to play in improving student understanding of these issues, as demonstrated by feasible and user-friendly CATs.

Background The Royal College of Physicians of Ireland (RCPI) recently reviewed medical education programmes in light of the international trend towards demonstrable measures of progress. Outcome Based Education (OBE) was selected as the most appropriate for the Irish system and the Paediatric Basic Specialist Training (BST) was chosen to be the pilot scheme. A curriculum was drafted after systematic review and surveying of trainers regarding the importance and frequency of tasks and focus groups. The existing ePortfolio used by BST trainees for recording training was overhauled to reflect the changes made to the curriculum and facilitate recording along the OBE model. Aim To evaluate the initial experience of Paediatric BST trainees of the OBE model and their interaction with the new ePortfolio. Methods At the beginning of the term all trainees were required to attend an induction day where the changes and model of training were outlined. Each trainee present also received training on how to use the ePortfolio system and incentives to promote engagement with the system discussed. RCPI first year Paediatric trainees were subsequently surveyed using a surveymonkey© questionnaire towards the end of their first post of training in December 2018. The individual timelines were also reviewed to assess engagement with the Kaizen ePortfolio. Results At the end of rotation 33/40 (82.5%) of trainees had completed a Personal Goal form and 32/40 had completed an End of Post form. During the 6 months 35/40 (87.5%) had completed a Directly Observed Procedure (DOPs) form with 195 separate DOPs recorded by this group. Trainers have signed off 88/195 (45%) of the submitted forms. 12 trainees had no work signed off by their trainers and 2 trainees have not submitted anything to be signed off. 19/40 (47.5%) of trainees responded to the questionnaire. The majority of responders recognise what is required of them to progress in the programme and the training opportunities available to them in the work place. The ePortfolio was most often accessed monthly to record activities Conclusion Early data indicates that using OBE is an effective method of facilitating better workplace feedback and evaluation in post graduate training. These findings demonstrate a successful introduction to the workplace and it has been well received. More training of Trainers appears to be needed and support for Trainees in using the ePortfolio and recognising their training opportunities. This will help to further improve the project before rolling out to other specialties.

BACKGROUND Speckle tracking echocardiography (STE) is a validated method to measure longitudinal deformation in premature infants, but there is a paucity of data on STE-derived circumferential and radial strain in this population. We assessed the feasibility and reproducibility of circumferential and radial deformation measurements in premature infants. METHODS In a prospective study of 40 premature infants (

BACKGROUND Subjective assessment of right ventricular (RV) function by neonatal echocardiography lacks validation. Incorrect diagnostic assignment in patients with suspected pulmonary hypertension (PH) may lead to unnecessary treatment or missed treatment opportunities. METHODS Six evaluators (experts [n = 3], novice [n = 3]) were asked to independently rate RV characteristics (global function, dilation, and septal flattening) based on standardized echocardiography images. We randomly selected 60 infants, ≥35 weeks gestation at birth, of whom 30 were clinically unwell with acute pulmonary hypertension (aPH) and 30 were healthy controls. aPH was defined by echocardiography presence of right-left shunting across transitional shunts or elevated right ventricular systolic pressure as estimated by the magnitude of the regurgitant jet across the tricuspid valve with impaired oxygenation. Inter-rater comparative evaluation within groups and between groups was performed using Kappa statistics. RESULTS Global agreement between evaluators for subjective assessment of RV function (0.3 [0.03], P

The objective of this study is to test whether myocardial performance is impaired over the first week of age in infants with Down syndrome (DS) without congenital heart disease (CHD). A prospective cohort study of 20 infants with DS without CHD and 17 healthy term infants comparing echocardiographic measures of left (LV) and right (RV) ventricular function and pulmonary hypertension (PH) on days 1, 2, and 5–7. Indices of PH were higher in the DS group over the study period. Infants with DS had larger RV and smaller LV dimensions. Fractional area change and RV longitudinal strain values were lower in the DS group. LV shear strain values were lower in infants with DS driven by a lack of basal rotation. Infants with DS without CHD and echocardiographic evidence of PH during the early neonatal period demonstrate reduced RV systolic function with impaired LV rotational mechanics, reflective of the ventricular interdependence.

Persistent pulmonary hypertension of the newborn (PPHN) is a relatively common condition which results in a mortality of up to 33%. Up to 40% of infants treated with nitric oxide (iNO) either have a transient response or fail to demonstrate an improvement in oxygenation. Milrinone, a selective phosphodiesterase 3 (PDE3) inhibitor with inotropic and lusitropic properties may have potential benefit in PPHN. This pilot study was developed to assess the impact of milrinone administration on time spent on iNO in infants with PPHN. This is a multicentre, randomized, double-blind, two arm pilot study, with a balanced (1:1) allocation of 20 infants. In this pilot study, we hypothesise that infants ≥34 weeks gestation and ≥ 2000 g with a clinical and echocardiography diagnosis of PPHN, intravenous milrinone used in conjunction with iNO will result in a reduction in the time spent on iNO. In addition, we hypothesise that milrinone treatment will lead to an improvement in myocardial performance and global hemodynamics when compared to iNO alone. We will also compare the rate of adverse events associated with the milrinone, and the pre-discharge outcomes of both groups. The purpose of this pilot study is to assess the feasibility of performing the trial and to obtain preliminary data to calculate a sample size for a definitive multi-centre trial of milrinone therapy in PPHN. Trial registration: www.isrctn.com; ISRCTN:12949496; EudraCT Number:2014–002988-16. Electronic supplementary material The online version of this article (10.1186/s40748-018-0093-1) contains supplementary material, which is available to authorized users.

Purpose The impact of Down syndrome on myocardial performance measured using deformation imaging and pulmonary hypertension (PH) in the neonatal period requires exploration. We aimed to assess PH and measure left (LV) and right (RV) ventricular function using deformation imaging in neonates with DS (without structural heart disease) over 5 days of age. Methods Echocardiograms were performed on Days 1, 2 and 5 to measure LV and RV dimensions, LV basal longitudinal strain (LV BLS) and systolic strain rate (LV SR), RV free wall basal longitudinal strain (RV BLS) and systolic SR (RV SR), and LV rotational mechanics. PH was assessed by examining ductal (PDA’s) shunting and tricuspid regurgitation (to estimate RV systolic pressure, RVSp). Values were compared with healthy controls. Results 17 infants with DS with a mean ±SD gestation and birthweight of 38.4±2.1 weeks and 3.1±0.5 Kg respectively were compared with 16 controls (38.3±2.0 weeks and 3.3±0.5 Kg). On Day 1, infants with DS had a higher proportion of bidirectional PDAs (100% vs. 20%, p Conclusion Infants with DS demonstrate elevated pulmonary pressures during the early neonatal period translating into lower RV function measured using deformation imaging. They also demonstrate impaired twist driven by reduced basal rotation. The clinical implications warrant further study.

High-risk neuroblastoma (HR NBL) treatment requires intensive induction chemotherapy. The profoundly emetogenic agents used can compromise nutritional status. Our institution introduced a new antiemetic guideline in 2010 incorporating regular dexamethasone, in addition to ondansetron, for all highly emetogenic protocols.A retrospective comparative review of pediatric patients diagnosed with HR NBL who received rapid COJEC induction chemotherapy as per HR-SIOPEN NBL trial. Prophylactic antiemetics were prescribed regardless of chemotherapy emetogenicity in group A (2004-2010) but for defined time periods considering chemotherapy emetogenicity in group B (2010-2017).Sixty-three children were eligible for inclusion (median age, 31 months; range, 1-88 months). Group A had more episodes of emesis than group B (189 vs. 116, P 0.0001). There was a significant difference in weight-for-age Z score change between the groups by induction end (P = 0.0027). Four children (13%) in group A lost10% body weight versus none in group B. Nutrition support (NS) was utilized by 29 children (94%) in group A and 22 children (69%) in group B. Group A had a median of 3 (range, 1-7) admissions for febrile neutropenia (FN) versus a median of 1.5 (range, 0-4) for group B (P = 0.003) during induction.The review of our guidelines led to reduced emesis frequency for group B. They also required less NS, followed expected growth trajectories more closely and had fewer FN admissions. We propose that this may have occurred due to better emesis control resulting in improved nutritional status and associated enhanced immune function.

Velvet crabs (Necora puber (L.)) are taken mainly as a by-catch in the pot fishery for large crustaceans. N. puber is negatively associated with spider crabs (Maja brachydactyla Balss) and positively associated with brown crabs (Cancer pagurus L.). In the Irish Sea, which yields small quantities of brown crabs, velvets have greater commercial significance, and they are targeted. Individuals from 28 samples of velvet crabs were described to characterise landings of the species. The female:male ratio was low, as was fecundity, which was typical of the northern European subgrouping of the species. Carapace width frequencies of males and females were disaggregated by a Bhattacharya plot into six groups of males and four groups of females. Females have been described as having a lower life expectancy than males in this species. An age of eight to ten years is proposed as the required age to achieve maximum size in the male. Average male and female size and weight within samples correlated highly significantly, and males were used as indicators of population structure as more information was obtained on males. Age at full recruitment of males correlated inversely with landings over a period of ten years; the mortality coefficient (Z) correlated positively with landed weights. There are no conservation measures currently in force in Ireland for this species, but it is difficult to hold in captivity, and most of the trade is live export. Hence this species is landed at 20-34% of potential landing places, only where suitable buyers are available, although the species is believed to occur in all coastal waters. Spatially discontinuous exploitation favours a sustainable velvet fishery.

Background Although subgaleal hemorrhage can present very soon after delivery with catastrophic consequences, subaponeurotic or subgaleal fluid collections are rare and clinically distinct causes of infant scalp swelling that present weeks to months after birth. Their exact etiology remains uncertain; however, they are frequently associated with instrumental and traumatic delivery. Aim & Methods To characterize 11 subaponeurotic fluid collections that presented to the Temple Street Children's University Hospital Emergency Department (TSCUHED) from July 2013 to July 2015 by a retrospective chart review. Case Report Eleven infants were identified with delayed subaponeurotic fluid collections. Of note, all infants were either successful vacuum delivery or failed vacuum delivery with subsequent forceps delivery or emergency caesarean section. All infants were otherwise well at presentation, and resolution of the scalp swelling occurred within weeks to months. Why Should an Emergency Physician Be Aware of This? This condition follows a benign course and conservative management is the treatment of choice.

Early diagnosis and effective treatment of the patent ductus arteriosus (PDA) in infants less than 32 weeks gestation remains contentious.To determine which clinical and echocardiographic parameters are associated with PDA patency in preterm infants less than 32 weeks gestation.This was a prospective cohort study. An echocardiography (echo) was performed within 12-48 h of birth and a follow-up echo at 1 month of life. Parental consent was obtained.55 babies were enrolled. Median (range) gestation was 28 (24-31) weeks and birth weight 1090 g (470-1800 g). ECHO 1 demonstrated that 50 babies had a PDA present within 48 h of birth, of which 19 were large (≥2 mm) (36%) and 31 were small (59%) on colour Doppler assessment of duct diameter. Three babies died before 1 month. At 1 month 30 babies still had a PDA (58%), 10 of which were large (19%) and 19 were small (36%). Parameters significantly associated with large PDAs versus no PDA at 1 month were gestational age (26 weeks vs 30 weeks, p=0.002), birth weight (860 g vs 1290 g, p=0.007) and ventilator support at 48 h (80% vs 17%, p=0.001). Echo parameters revealed that ductal size on colour Doppler (2.5 mm vs 1.5 mm, p=0.003), end diastolic flow velocity (57 m/s vs 147 m/s, p0.001) and peak systolic to end diastolic flow velocity ratio (2.29 vs 1.23, p=0.001) at 48 h were associated with large PDAs at 1 month.For infants less than 32 weeks gestation a peak systolic to end diastolic flow velocity ratio2 within 48 h of birth is associated with a persistent large PDA at 1 month of age.

Background : Medical students are often considered by anaesthetists to have a lack of knowledge of anaesthesia and the role of the anaesthetist. Aim : The aim of this study was to assess the impact of a clinical clerkship in anaesthesia on Irish medical students understanding of anaesthesia as a specialty, the role of anaesthetists and career choice through comparison of pre-clinical and clinical medical students. Methods : This was a cross sectional study of 80 Irish medical students who completed an anonymous questionnaire consisting of 16 items. Results : Only 47.5% of clinical students were aware that anaesthetists participate in running intensive care units and just 65% knew that anaesthetists were involved in the management of chronic pain. However, 100% of clinical students recognised that anaesthetists administered epidural analgesia to obstetric patients and 30% of clinical students would consider a career in this specialty. Conclusion : This research is providing medical professionals and educators with updated information which may be useful for improving students experience and understanding of anaesthesia.

A decade of service by the Regional Drug Information Service in Northern Ireland, and the need for this service to solve drug problems is described. The development of a combined Drug Information Service and Poison Information Service at the Royal Victoria Hospital, Belfast, is outlined.