Profile of Children Ventilated in Paediatric Intensive Care Unit of a Tertiary Care Hospital

INTRODUCTION: Ventilatory support is an essential and a common form of therapy in Pediatric Critical Care Unit. In recent years, this modality has evolved into a highly specialized discipline (1). The term mechanical ventilation refers to various artificial means used to support ventilation and oxygenation (2). Natural spontaneous ventilation occurs when the respiratory muscles (diaphragm, intercostal muscles) create negative intrathoracic pressure, in part by expanding the rib cage, leading to lung expansion, which pulls air into the alveoli and allows gas exchange to occur. In contrast, ventilation is achieved in intubated patients by delivering compressed gas to the lungs by positive pressure ventilation. During positive pressure ventilation, the flow of gas during inspiration and expiration is driven by the airway pressure gradient between the airway opening and the alveoli. During inspiration, the airway opening pressure is greater than alveolar pressure, thereby driving gas into the lungs and inflating them. Expiration is usually passive and occurs because, at the end of inspiration, alveolar pressure becomes greater than airway pressure. AIM OF THE STUDY: To study the etiological and clinical profile of children ventilated in PICU and various complications and outcome of these children. DISCUSSION: This descriptive observational study was conducted to study the demographic, clinical profile of children who were ventilated at the PICU, and their complications and outcome. The commonest indication for intubation and artificial ventilation was circulatory dysfunction including shock, unlike other studies,where neurological indications predominated in the study by Kendirli et al and respiratory causes were the commonest causes for artificial ventilation in the study by Indrajit et al. Intubation was performed orotracheally in 97.9% of children and nasotracheally in 2.1% in present study compared to no nasotracheal intubation performed in the study by Da Silva et al. Rapid Sequence intubation(RSI) was performed in 54.8% of the study population compared to routine RSI protocol used in the study by Da Silva et al. Though mechanical ventilation is the standard of care, our hospital being a Government hospital and a tertiary referral centre, many critically ill children with need for ventilation are being referred to here, which could not be met by the available resources in PICU and hence, many children needed manual ventilation. Out of the 106 children who were manually ventilated, 45 (42.5%) survived. Another 75 children required manual ventilation for varying duration in addition to mechanical ventilation, and the survival was 52.1% in that subgroup. None of the studies in available literature have data on manual ventilation. The mean duration of artificial ventilation in the study was 3.56±5.2 days. The duration of mechanical ventilation in the study was 4.6±5.9 days. A total of 181 children (96.3%) were ventilated manually during their PICU stay, and among them, 75 children were ventilated mechanically after variable duration of manual ventilation. In comparison, the ventilation days were 18.8±14.1 days in the study by Kendirli et al and the median ventilation days were 6.5 days in the study by Da Silva et al. SUMMARY AND CONCLUSIONS: 1. Infants contributed 46.3% of children who were ventilated in the Pediatric Intensive Care Unit. 2. The sex ratio was almost equal with slight male preponderance. Male:Female = 1.09:1.0 3. The commonest cause for intubation was circulatory failure and the commonest clinical diagnosis was septic shock. 4. Of the children who were ventilated in the PICU, 76.6% were intubated at the Emergency Department. 5. Rapid Sequence Intubation was performed in 54.8% of children, and orotracheal route was the commonest route of intubation. • Many children (56.4%) were manually ventilated and it was associated with an increased risk of mortality especially when done for 48 hours or more. 6. Nosocomial pneumonia was the commonest complication encountered in ventilated children and was more common in those who were reintubated. 7. Mortality and complications in ventilated children in the PICU can be reduced with increased availability of mechanical ventilators

Neutrosophic Project Evaluation and Review Techniques

One of the most important and challenging jobs that any manager can take in the management of a large scale project that requires coordinating numerous activities throughout the organization. Initially, the activity times are static within the CPM technique and probabilistic within the PERT technique. Since neutrosophic set is the generalization of fuzzy set and intuitionistic fuzzy set, a new method of project evaluation and review technique for a project network in neutrosophic environment is proposed in this paper. Considering single valued neutrosophic number as the time of each activity in the project network, neutrosophic expected task time, neutrosophic variance, neutrosophic critical path and the neutrosophic total expected time for completing the project network are calculated here. The main concept of Neutrosophic Project Evaluation and Review Technique(NPERT) method is to solve the ambiguities in the activity times of a project network easily than other existing methods like classical PERT, Fuzzy PERT etc.The proposed method is explained by an illustrative example and the results are discussed here

Choosing project risk management techniques. A theoretical framework

The pressure for increasing quality while reducing time and costs places particular emphasis on managing risk in projects. To this end, several models and techniques have been developed in literature and applied in practice, so that there is a strong need for clarifying when and how each of them should be used. At the same time, knowledge about risk management is becoming of paramount importance to effectively deal with the complexity of projects. However, communication and knowledge creation are not easy tasks, especially when dealing with uncertainty, because decision-making is often fragmented and a comprehensive perspective on the goals, opportunities, and threats of a project is missing. With the purpose of providing guidelines for the selection of risk techniques taking into account the most relevant aspects characterising the managerial and operational scenario of a project, a theoretical framework to classify these techniques is proposed. Based on a literature review of the criteria to categorise risk techniques, three dimensions are defined: the phase of the risk management process, the phase of the project life cycle, and the corporate maturity towards risk. The taxonomy is then applied to a wide selection of risk techniques according to their documented applications. This work helps to integrate the risk management and the knowledge management processes. Future research efforts will be directed towards refining the framework and testing it in multiple industrie

Predictors of Response to Hydroxyurea and Switch to Ruxolitinib in HU-Resistant Polycythaemia VERA Patients: A Real-World PV-NET Study

: In polycythemia vera (PV), the prognostic relevance of an ELN-defined complete response (CR) to hydroxyurea (HU), the predictors of response, and patients' triggers for switching to ruxolitinib are uncertain. In a real-world analysis, we evaluated the predictors of response, their impact on the clinical outcomes of CR to HU, and the correlations between partial or no response (PR/NR) and a patient switching to ruxolitinib. Among 563 PV patients receiving HU for ≥12 months, 166 (29.5%) achieved CR, 264 achieved PR, and 133 achieved NR. In a multivariate analysis, the absence of splenomegaly (p = 0.03), pruritus (p = 0.002), and a median HU dose of ≥1 g/day (p < 0.001) remained associated with CR. Adverse events were more frequent with a median HU dose of ≥1 g/day. Overall, 283 PR/NR patients (71.3%) continued HU, and 114 switched to ruxolitinib. In the 449 patients receiving only HU, rates of thrombosis, hemorrhages, progression, and overall survival were comparable among the CR, PR, and NR groups. Many PV patients received underdosed HU, leading to lower CR and toxicity rates. In addition, many patients continued HU despite a PR/NR; however, splenomegaly and other symptoms were the main drivers of an early switch. Better HU management, standardization of the criteria for and timing of responses to HU, and adequate intervention in poor responders should be advised

Choice of Frontline Tyrosine-Kinase Inhibitor and Early Events in Very Elderly Patients With Chronic Myeloid Leukemia in Chronic Phase: A "Campus CML" Study

Objectives: The study aimed to evaluate the utilization of frontline TKI therapy in a large cohort of elderly CP-CML patients. Methods: A retrospective analysis was conducted on 332 CP-CML patients aged 75 years or older among 1929 diagnosed from January 2012 to December 2019 followed at 36 participating Hematology Centers involved in the "Campus CML" project. Results: Among the patients analyzed, 85.8% received imatinib (IM) while 14.2% received second-generation TKIs (2G-TKI), 59.5% dasatinib, and 40.5% nilotinib. Most patients initiated IM at standard dose (67.3%) while 32.7% at reduced dose. A similar trend was observed with 2G-TKIs. The cumulative incidence of permanent TKI discontinuation at 12 months was 28.4%, primarily due to primary resistance (10.1%) and extra-hematologic toxicity (9.5%), with no significant difference between IM and 2G-TKI groups. Following the introduction of generic IM in Italy in 2018, IM usage increased significantly compared with 2G-TKIs. Conclusions: IM was in our Centers the preferred frontline therapy for older CP-CML patients, with increasing utilization after the introduction of generic formulations. However, 2G-TKIs are still used in a substantial proportion of patients, suggesting individualized physician assessments regarding patient suitability and expectations. Further investigation is needed to assess efficacy and safety of reduced TKI doses in this patient population

Neutrosophic EOQ Model with Price Break

Inventory control of an ideal resource is the most important one which fulfils various activities (functions) of an organisation. The supplier gives the discount for an item in the cost of units inorder to motivate the buyers (or) customers to purchase the large quantity of that item. These discounts take the form of price breaks where purchase cost is assumed to be constant. In this paper an EOQ model with price break in inventory model is developed to obtain its optimum solution by assuming neutrosophic demand and neutrosophic purchasing cost as triangular neutrosophic numbers. A numerical example is provided to illustrate the proposed model