Jan - March 2021 - Issue 1
Editor : President Dr. Prashant Kariya Dr. Yogesh Parikh Secretary Dr. Manish Mehta AOP GUJARAT Academy of Pediatrics - Gujarat (2021 ) Office Bearers
President Secretary Treasurer Imm. Past President President Elect Dr. Yogesh Parikh Dr. Manish Mehta Dr. Bharat Prajapati Dr. Hiren Patel Dr. Rakesh Desai Invited Members – CIAP
Prof. Dr. Piyush Gupta Dr. G. V. Basavraj Dr. Remeshkumar Dr. Sandeep Trivedi Dr. Chetan Trivedi CIAP President 2021 CIAP Hon. Secretary CIAP-President 2022 EB-CIAP EB-CIAP EXECUTIVE BOARD MEMBERS North Zone South Zone Ahmedabad Zone
Dr. Divyang Patel Dr. Monish Shah Dr. Vijay Shah Dr. Prashant Kariya Dr. Jayanti Gosai Ahmedabad Zone Saurashtra Zone Central Zone
Dr. Amar Patel Dr. Jayendra Gohil Dr. Rajan Ramani Dr. Tushar Shah Dr. Samir Shah 02 AOP GUJARAT
ACADEMY OF PEDIATRICS - GUJARAT (2019) Society Reg. No : GUJ / 13286 / Ahmedabad Public Trust Registration No : F / 13148 / Ahmedabad
President : Dr. Yogesh Parikh Hon. Secretary : Dr. Manish Mehta Editor : Dr. Prashant Kariya
Secretarial address : Dr. Manish Mehta Synergy Neonatal & Pediatric Centre 2nd Floor, Vishwam Complex, Dharnidhar Cross Road, Vasna, Ahmedabad-380007. E-mail : [email protected], [email protected]
Editor Correspondence address : Dr. Prashant Kariya Param NICU & Children Hospital 801-803 Param Doctor House, Near Resham Bhavan, Laldarwja, Surat – 395003 Email: [email protected]@gmail.com
The views expressed in the articles are those of the contributors and not necessarily of the editor or publisher of the AOP, Gujarat
03 AOP GUJARAT Editor's Message Dr. Prashant Kariya Dear Friends, It gives me immense pleasure to write Editorial message for the official magazine of Academy of Pediatrics, Gujarat.The whole world is going through covid crisis. There are increasing number of cases in pediatrics also. We are daily getting the calls asking for the oxygen beds, availability of ventilators, availability of medicines and so on. The virus has mutated and done lot of damage to humans but humanity still wins the battle. The only hope in this tough time is vaccination. The beauty of this difficult time is that we got more time with the family and some of us have done introspection and became more wonderful souls. The new team under able leadership of Dr. Yogesh Parikh took this challenge positively. Firstly, AOP Gujarat hybrid conference was a grand success and appreciated by all. Learning from the same experience AOP Gujarat team has launched the dream project – E- Gurukul on dIAP Platform. We are having weekly twice E-Gurukul sessions on dIAP which is becoming more popular in this covid time which is somewhere replacing our usual CMEs/Conferences. I have selected few of the academic platters from the E Gurukul to be included in our official magazine. The key attractions of the bulletin are · Excellent academic articles from E-Gurukul & many others which will be useful in current situation · Knowledge is power series · Yuva Mitra Series · Travel blog · Quiz from the articles of bulletin – exciting prizes for the winners. · Neonatology Crossword – again a bumper prizes for the winners. At last, I urge all to self-instigate & come forth with original articles in areas of expertise to make our bulletin readable and learnable. Do not forget to share your & your family's achievements for due acknowledgement in this magazine. Wishing to catch up with you all in person soon! Stay safe, healthy, alert & take care of your near & dear ones! Pledge do propagate vaccine advocacy to eligible candidates as this is the only weapon in our armamentarium against a lethal enemy. The world will be known as “Pre Covid” & “Post Covid” Era. In this tough time, child in me reminds me of a dialogue – “Hakuna Matata” Dr. Prashant Kariya Bulletin Editor Academy of Pediatrics, Gujarat 04 AOP GUJARAT IAP President Message
Dr. Piyush Gupta IAP President 2021
My dear fellow IAPians, COVID 19 pandemic has given us many challenges and we have accepted the challenges. We have come up with dIAP platform and the same is given to all state branches. I am happy that AOP Gujarat under the leadership of Dr. Yogesh Parikh is doing E-Gurukul programs regularly. Indian Academy of Pediatrics is committed to improving health of children by imparting latest education and training of members and other stakeholders of child health. Under IAP President action plan we are launching “Nurturing care for Early childhood development” which will be our flagship program for the year 2021-22. We are planning to conduct five national zonal ToT and then in two years we will be doing around 200 training workshops in which we will be training around 10000 pediatricians. One more dream project of central IAP which is running since a decade is “First Golden Minute – Neonatal Resuscitation Program” and I am glad to share with all of you that now we have a hybrid model of training of the same. The video based MCQ is being appreciated by all and then the hands-on training is becoming easier. Many of our members are actively doing social community work in various aspects of child health. I request them to report to central IAP as we being a charitable trust needs to report the social activities. For any professional organization, its members are the real strength and we need to strengthen our organization by motivating and enrolling the pediatricians as life member of IAP. I appeal each one of you to makeat least one new member and expand our association. Friends, if you have any new idea or suggestion please send me by sending email on my designated official email address:[email protected], so as we can incorporate in the activities of year 2021. With warm regards to one & all In the service of academy Dr. Piyush Gupta IAP President 2021 05 AOP GUJARAT AOP Gujarat President's Message
Dr. Yogesh Parikh Rajkot Dear AOP Gujarat Members Season's Warm Greetings to all of you It's my honour & privileged that I am bestowed upon the responsibility of president of esteemed AOP Gujarat & I promise that I will try to live up to the expectations of all of you. Despite challenges posed by COVID-19, we are determined to work at our best capacities in the service of AOP Gujarat. The first challenge that we faced was to organize the annual conference of Academy of Pediatrics, Gujarat. COLORS GUJPEDICON was the first Hybrid conference at Lords Inn Vishal Greenwoods Resort, Sasan Gir and we were lucky that all five national presidents- Dr. Santosh Soans, Dr. Digant Shastri, Dr. Bakul Parekh, Prof. Dr. Piyush Gupta & Dr. Remeshkumar & Hon. Secretary Dr. G V Basavraj blessed us with their presence in the conference. The conference was well appreciated and participated by all. We have done BNCRP ToT & NTEP workshop in the conference. Once again thank you one and all for participating and making the conference a memorable one. We have also released the souvenir which covered the good clinical practices in covid time and it was well appreciated by all. One of the dream project of mine is E-Gurukul which was launched by infectious disease CME & installation function of Surat Pediatric Association Charitable trust. The launch was blessed by our beloved president Prof. Dr. Piyush Gupta. He emphasized on Early Childhood Development and his dream of conducting the 200 workshops on Nurturing Care through Early Childhood development. Under the able guidance of Dr. Digant Shastri- Chairperson of the steering committee, I am given responsibility of national coordinator of the same workshop. We dream to train around 10000 pediatricians in two years and with all your due support, we will definitely turn this dream into reality. I am happy to see my young EC team becoming active from the beginning of the year. You can see their contribution by compilation of all zones report in this bulletin. Inspite of the adversities we have continued to do many academic activities throughout the first quarter.
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One of the most applauded program is our PG Teaching where the young budding pediatricians are presenting their cases in front of the teachers from the various national medical colleges. There are so many programs of AOP Gujarat which are running since a year and we have decided to continue all the programs in partnership with UNICEF, Government of Gujarat and other organizations. To name the few we have decided to continue and also to add few more academic topics in current projects like IMPACT, INTACT, TRUMPPS, PARVAH and so on . We have done Blood donation activities in difficult time of covid 19 to support needy poor children and mothers. On 14th February we had organized blood donation camp at Rajkot by AOP Rajkot branch & at Deesa by AOP BK branch. I request you personally to arrange atleast one blood donation camp by your branch and support our noble endeavour. I congratulate Dr Nehal Patel and Dr Shwetal Bhatt for forming Women Wing of AOP GUJARAT. I am sure under their dynamic leadership with guidance of senior patrons, advisors and active efforts of WW young EC TEAM. The legacy of the AOP Gujarat is like a milestone which will inspire me and AOP Gujarat team to work relentlessly. I assure that with your support, we will definitely reach to new milestone. So let's start working together and “Make Dreams Real” In the service of AOP Gujarat STAY SAFE STAY HEALTHY Please take care of Your Self And Your Family Members Dr. Yogesh Parikh President
Swami Vivekananda says
*“ sound mind in a sound body “*
Our body is vehicle and our mind is driver, If vehicle is good in condition and driver is healthy enough, Our journey will be good Let’s join on journey of *“ Fit hai to hit hai “* 07 AOP GUJARAT President Elect's Message
Dr. Rakesh Desai Dear. Colleagues, It's my pleasure to connect to all of you by means of AOP Gujarat's most prestigious bulletin by the virtue of president elect 2021. I thank you all for selecting me unanimously as AOPG president 2022. I feel it an honour, indeed a very great honour to be the president of our most prestigious branch in the history of IAP. Your unending faith in me will be reciprocated with utmost sincerity. I will try my best to ensure that I stay true to your expectations. The year 2021 started with a bang, with the grand success of Gujpedicon2020, under the able leadership of Dr Yogesh Parikh. It was first of its kind physical conference since the pandemic, with the sign of hope of returning to normalcy. Unfortunately pandemic showed it's ugly face once again and situation is getting worse, with the fear of exhaustion of resources. May God give all of us courage to stand up in this testing times. New team is fully charged and is working with great zeal. President's action plan E Gurukul is very popular and accepted by all. PG Clinic by Dr Baldev Prajapati is also acclaimed by all. Viewership data of both speaks volumes of its success. Great efforts of Dr Yogesh Parikh, Dr Manish Mehta, Dr Abhay Shah, Dr Chetan Shah and many, really deserve great applause. I congratulate Dr Yogesh Parikh, Dr Sandip Trivedi and Dr Chetan Trivedi for being unanimously elected as CIAP EB members. We are approaching near to midterm conference at Patan. I pray almighty and hope to see you all physically at Patan. We, the spactians, have also geared up for GUJPEDICON2021, at Avadh Utopia Surat on 18th and 19th December with pre conference workshops on 17th Dec. Most of the preliminary work, including scientific program is finalised. You will get e brochure soon. I request all of you to get registered for the conference. It is going to be one of its kind event in the history of AOPG. I hope you stay safe and healthy and take care of yourself and your family. In the service of AOP Gujarat, Dr Rakesh Desai. President elect 2021. 08 AOP GUJARAT Hon. Secretary's Message
Dr. Manish Mehta
Dear Friends,
After a short period of relief from Covid Pandemic fear, we all have again entered into the same phase of uncertainty and insecurity. But AOP Gujarat under the able leadership of our beloved president Dr Yogesh Parikh has come out with completely new way of learning and thats E-learning. At one point of time we thought we wont be able to have many academic activities this year too due to covid pandemic, but on the other side with AOP Gujarat team has come up with shower of academic sessions with stalwarts of the field.
Year 2021 started with the most awaited conference of AOP Gujarat – Colors Gujpedicon 2020. It was organized in the serenity and beauty of Sasan Gir during 8-10 January of this year. With all due precautions of corona infection prevention, it was a great mixture of academy, festivities, delicacies and celebration. After almost one year we all could gather at one place physically with office bearers of present and past of CIAP team.
AOP Gujarat Action plan was announced during the conference. It consists of academic activities like E gurukul, PG Clinics, IMPACT, INTACT, PARVAH, various social activities with UNICEF and Government of Gujarat.
New team of AOP Gujarat was announced during the conference which is full of energy and enthusiasm. All the Executive Committee members of the team are dynamic and full of innovative ideas.
E Gurukul-AOP Gujarat action plan has already started and appreciated not only in Gujarat but also all over India and by our pediatric friends at abroad also. Program involves experts in the field and so far we have done webinars on Nutrition in children, Neurological disorders in children, Respiratory issues in children, topics on neonatology, pediatric nephrology and still lot more to come. Dr Abhay Shah is convenor of this program and Dr Chetan Shah is coordinator for this program. 09 AOP GUJARAT
Apart from that we have PG clinics every Saturday which under the guidance of our teacher and a great academician Dr Baldev Prajapati involves various PG teachers from different medical colleges with their residents, who present case in presence of other experts and is truly a great learning experience not only for PG students but for practicing paediatricians too.
With our request AOP Rajkot and Banaskantha have arranged blood donation camps in their cities and had a grand success and contributed great help to the society when blood donation is hugely affected due to covid pandemic.
TRUMP module was also done at Rajkot and Ahmedabad and was attended by around 40-50 nursing students and was well appreciated by all the staffs who attended it.
We are coming with many other programs like IMPACT, INTACT, PARVAH in its new form and many more activities with UNICEF and GOG.
This year we have established AOP women's wing, with the support of AOP Gujarat team and efforts from Dr Nehal Patel and Dr Shwetal Bhatt now AOP Gujarat has launched women's wing and they have started their programs too. Working committee for the wing has been established and almost more than 150 members are already there in the wing.
Hoping to have a control of this covid pandemic soon and expecting to have our Mid Term Scientific meet planned on 30th May 2021.
We welcome our new Executive Board members of the year 2021 and CIAP EB members to our team.
“OPTIMISM IS THE FAITH THAT LEADS TO ACHIEVEMENT. NOTHING CAN BE DONE WITHOUT HOPE AND CONFIDENCE.”
Visit Our Website : www.iapgujarat.com Online Membership Form available Be member of AOP Gujarat & Central IAP
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7th Year Running
11 AOP GUJARAT Nurturing Care – Early Childhood Development NC-ECD
Prof. Dr. Piyush Gupta IAP President 2021 The first three years of life are critical. This is the period in which maximal brain growth occurs, child-parent attachments are formed and pre-academic learning starts. Early child development (ECD) is dynamic and influenced by genetic, biological, psychosocial and environmental factors. In 2017 Lancet reported that around 250 million (43%) children under 5 years, from low- and middle-income countries (LMIC) were not reaching their expected developmental potential. This is due to adverse factors ones like (i.e. poverty, stunting, etc) significantly outweighing protective ones (i.e. educated parents, stimulatory home environments, etc). This imbalance negatively affects brain growth, physical health and psychological development in young children that results in faltering or a downward deviation of the developmental trajectory.
There has been a constant debate on the role of 'nature' versus 'nurture' in ECD. Various agencies dealing with ECD like WHO, UNICEF, Early Childhood Development Action Network (ECDAN), Partnership for Maternal, Newborn and Child Health (PMNC) have been working on ECD over the years. This lead to the development of the model 'Nurturing care for ECD (NC- ECD)' which is a holistic approach that is envisioned to provide a framework for not only survive and thrive, but to go to the next phase, i.e. to transform health and human potential. This comprises of the following components that are evidence based and proven to be effective in LMIC; Good health, Optimal nutrition, Opportunities for early learning, Responsive parenting and Safety and Security. It is believed that the provision of nurturing care can enhance child development even in the presence of adversities. Training modules have been developed for community health workers that can be adapted according to the point of evolution a country is in terms of NC and ECD [5]. The strategic actions include; i) Lead and invest, ii) Focus on families and communities, iii) strengthen services, iv) Monitor progress and v) Use data and innovate.
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Magnitude of burden in India
India's country profile in the Countdown to 2030 Women's, Children's and Adolescent's Health (CD2030) estimates that 45% children under 5 years are at risk (70 million by current census) The 2030 Sustainable Development Goal (SDG) 4.2 is 'By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education'. One of the corresponding indicators (4.21) is the proportion of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being, by sex.
Currently health care seeking attitudes of most parents are for medical attention related to acute/ chronic illnesses or for immunization. The concept of a well child visit in which other aspects of child health and well-being are discussed, evaluated and addressed is foreign to both parents and pediatricians. For India to meet the 2030 4.2 SDG there needs to be a paradigm shift in the knowledge, attitudes and practices of all stake holders; policy makers, service delivery health personnel, families and parents.
The year 2020 is an exciting time of transition. India has recently pledged its commitment to promoting ECD in its health policies in several platforms. The roll out of the RashtriyaBalSurakshaKaryakram (RBSK) is proof of this. However, there is still a lot of ground to be covered in the next decade and this can only be achieved if the private health sector that serves the major chunk of children in our country also joins the initiative to help our children survive, thrive and transform.
This can only be achieved if we start promoting the concept of well child visits in the public so that they realize that it is a strong felt need for their children. We know from past experience with immunization and Infant and young child feeding programs that getting the community to change their behavior is a mammoth task. But it has to be done and the time is ripe. However, the only way parents can be convinced about nurturing care and its benefit on ECD is if we the community of pediatricians share this belief and are willing to incorporate it into our own clinical practice with conviction and dedication.
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14 AOP GUJARAT Effective Breastfeeding : Making a case for relearning the technique and skills of counselling
Rupal Dalal, MD, IBCLC Devaji Patil, MBBS, MHA Introduction TIBF and EBF are well known indicators with universal use and acceptance. Both these indicators do not pick if enough milk transfer had taken place. If Breast feeding is exclusive and the growth of the child falters then breastfeeding skills need to be reassessed and improved. There is currently no way in which mothers learn about positioning and latching techniques, when it is increasingly realized that this is critical to catch up weight gain in the baby and to prevent growth faltering. Only 7.5% of the mothers are reported to be practicing correct breastfeeding technique in urban slums of East Delhi in one of the studies. We are enduring a myth that breast feeding is natural and the mother-child dyad will “somehow” find what is best suitable for both and an intervention is not needed. Nothing could be more far from truth. The non-alignment of mothers' expectation about breast feeding and the reality has been identified as a key reason that many mothers stop breastfeeding within the first two weeks postpartum. Breast feeding assessment studies do indicate 9 out of 10 mothers showed more than one concern as early as day 3, the common ones were difficulty with infant feeding at breast, breastfeeding pain and milk quantity. If unaddressed, these are found to worsen and leading the mothers to stop breastfeeding and start formula use. Difficulty in breast feeding and milk quantity have the largest population attributable risk Effective Breastfeeding Technique Cross cradle hold with U support was used by the author in various NGOs working on maternal and child health with an excellent results as the stress was given not only on latching of lower areola but also on mother's comfort, baby's position, holding of breast in such a way so as to have a deep attachment, frequency of feeding, night time feeding and many other counseling points. Front line workers including the AWW, ASHA and the ANM and medical officers, from various states are being trained on this breastfeeding skill and counselling. There is a very good response from the community because of excellent weight gain among babies. In-fact, two of the Anganwadi workers who were trained in Melghat area of Amravati, Maharashtra received Poshan Award by Vice President of India last year. 15 AOP GUJARAT
“Cross-Cradle Hold” with U Support: Counseling Points for Effective Breastfeeding Mother's Preparation Ÿ Wash and dry hands with soap and water Ÿ Drink boiled and cooled water Ÿ Sit on the floor or bed or chair with proper back support Ÿ Keep back straight Ÿ Keep shoulders relaxed (not elevated/curved) Ÿ Uncover the breast Ÿ No pressure of bra/blouse on the breast Ÿ Unwrap the baby from a blanket while feeding Ÿ Hold the baby's head by opposite hand from the breast that the baby will be fed (Image 1) Ÿ Baby's legs tucked under an armpit of an opposite hand (Image 2) Ÿ Elevate baby to reach the breast (Image 3)
Position of mother's thumb & fingers • Mother's thumb behind one ear and rest of the fingers behind another ear of the baby; fingers should not be on the neck or pushing the head • Wrist should rest between baby's shoulder blades (Image 4) Baby's Position • Baby's body should be gently pressed against the mother's body (Image 5) • Head, neck and body should in a straight line (Image 6) • Nose should be in the line with the nipple (Image 7) • Baby's full body should be supported • Chin should be brought forward and close to the breast by extending the neck out a little bit (Image8) 16 AOP GUJARAT
Holding Breast while helping baby to latch the baby • Cup her breast underneath with U shaped hold (using the hand on the side of the breast baby is feeding from) (Image 9) • Mother's one finger should be at 9'0 clock position and other finger should be at 3'0 clock position on the breast (Image 10). Please note that the tip of the fingers should be at 9'0 clock & 3'0 clock position • Tip of the thumb and the finger should be at 3 finger distance from the nipple (Images 11 & 12)
• Mother's fingers should be parallel to the baby's lips (Images 13 & 14) • Compress the breast while latching the baby so that the areola can be contoured and baby can get a big chunk of lower areola in the mouth (Images 15 &16) • Equal compression of breast using thumb and fingers Avoid V-shaped compression which will result into nipple feeding
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Latching • Bring the baby to the breast in such a way that baby's nares are pointing towards the nipple and the neck is extended just like how we extend our neck while drinking the water. • To open the mouth widely, mother should touch her nipple to baby's upper lip (Image 17) • Extension of baby's neck also helps to open the big mouth • When baby opens her big mouth, glide the breast in the mouth immediately, sometimes it may take a few minutes but it is utmost important to wait patiently for the baby to open the big mouth • Two-point latch. Latch the lower lip first and then the upper lip. An upper lip should be resting just above the nipple and lower lip should be resting at the border of areola and the breast (Images 18 & 19)
• Lower lip curved outwards (Image 20) • In big breasts/well attached baby, press the breast upward near the lower lip to check if significant part of lower areola is in the mouth (Image 21). This is an important step to assess the deep attachment & must be encouraged by the mother • Chin should be embedded well in the breast (Image 22) • Once the latch is examined and the deep attachment is confirmed, the mother can remove the hand from the breast and bring it behind the baby, supporting the back. It is important that opposite hand should not be released from the nape of the neck of the baby
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Other Counseling Points • Feed from one breast completely before offering the other • To see if one breast is completely emptied or not, express the milk little bit and see. If milk is watery and thin or if the thick milk is flowing copiously then continue to feed from the same side • Give both foremilk (thin, watery, made up of protein) and hind milk (thick, yellowish and made up of fats) to the baby • Burp baby before offering another breast. The best position to burp the baby is in sitting position where baby's jaw is supported by mother's fingers and baby's chest is supported by mother's palm (Image 29) • Wake up the baby if he/she falls asleep while feeding by –Tickling on the feet, on the back, behind the ears or making baby sit in burping position • Use clean little finger to release the hold of the baby on the breast just in case baby latches onto nipple or baby falls asleep on the breast • If baby's nose is pressed on the breast-extend the head slightly. Do not pull off the baby from the breast • Signs of proper latching-Baby's cheeks are filled and do not dimple, no fast suckling sound, jaw drops slowly and distinctly • Breastfeed 10-12 times in 24 hours as per hunger cues in 1st 2-3 months then the frequency decreases • Breastfeed 2-3 times at night • Feed the baby on early hunger cues-squirming, stretching, opening the mouth; if the baby cries then it's too late (Images 23-28)
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• Growth periods 2 weeks, 6 weeks, and 3 months when baby's demand will increase. Feed frequently during increase demand
ŸContinue exclusive breastfeeding till 6 months of age and then continue breastfeeding with nutrient dense complementary foods till at least 2 years of age or more
Spoken Tutorials (ST) an innovative approach to improve breastfeeding practices Initiated with a vision to curb Infant mortality and spread awareness on malnutrition, the Spoken Tutorial is a multi-award-winning educational content portal which offers self-paced, multi-lingual courses that ensure self-determined learning. Created using simple words with excellent graphics, the ST has evolved over the years responding to the learners needs covering almost all the IYCF topics with translations available in more than 15 Indian languages. Enabling the learner at basic as well as advanced level the ST, like simple DIY tools, take the learner through an interesting problem-solving journey. The content is digital and the principle is empathy driven. The ST motivates an empathetic learner who is keen to solve a problem and enables the problem-solving though brilliant yet simple visualization and a down to earth explanation, of concepts that are difficult to grasp. Learners form skill–practice groups on social media, ably assisted by the real time technical support both online (chat box) and offline(helpline). The Learners understand the linkage between attachment–milk transfer and appropriate weight gain. Growth monitoring thus ceases to be a passive exercise but rather an
20 AOP GUJARAT active living phenomenon linked to skill and this is one of the main features of the entire model. Through these trainings, it has been possible to reach thousands of mothers and care-givers in rural areas of Maharashtra, Gujarat, Rajasthan, Madhya Pradesh, Goa. A total of 75+ tutorials are planned in this series. The Spoken Tutorial project is funded by the National Mission on Education through Information and Communication Technology (ICT), launched by the Ministry of Human Resources and Development, Government of India. The use of spoken tutorials to popularize software learning and its use is coordinated through the website https://spoken-tutorial.org/. For health and nutrition related videos, Health Spoken Tutorial Channel of YouTube has been created which can be accessed by anyone with the smart phone and data connection. All the content published on this website are shared under the CC BY SA license.
https://www.youtube.com/channel/UCmyV3lKT1Gs1AfgtV8pp__Q
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Dr. Chetan Dave has done his pediatric endocrine fellowship under Dr. Anurag bajpai (India – 2017-2019). He got scholarship for Allan Drash Fellowship by ISPAD (international society for pediatric and adolescent diabetes), for which he visited Rainbow babies’ and children’s hospital, Cleveland, USA under the mentorship of Dr. Jamie Wood. Finally he selected for ESPE (european society of pediatric endocrinology) and visited Liverpool, UK (under the mentorship of dr. Senthil Senniappan). He has started his CPED (center for pediatric endocrinology and diabetes) from july 1, 2020 at Rajkot, Gujarat. He has presented many papers in national and international conferences and contributed chapters in various books related to pediatric endocrinology( Expertise in MedEclasses Pediatric endocrinology, IAP textbook of pediatric endocrinology, Recent advances in Pediatrics by IJP and Pediatric • GROWTH & OBESITY emergencies by Meharban Singh). • DISORDERS OF SEXUAL DIFFERENTIATION (DSD) • EARLY & LATE PUBERTY • PCOS & FERTILITY ISSUES • CALCIUM & BONE ISSUES • GLUCOSE ISSUES & DIABETES • THYROID ISSUES • CONGENITAL ADRENAL HYPERPLASIA (CAH) & ADRENAL ISSUES • GENETIC SYNDROMES • METABOLIC DISORDERS • NOVEL RESEARCH
22 AOP GUJARAT Myths & Misconceptions related to Child Nutrition Dr Satish Tiwari MD (peds) LLB Professor of Pediatrics Dr P D M Medical College Amravati, Maharashtra E-mail: [email protected] The “Food, Clothes, Home & Health” are basic needs of each & every Human Being. In IYCF the first“1000 days” (9 months Antenatal + 2 years after birth) & the first “Golden Hour” after the birth are “critical window of opportunity” for reducing childhood disease & deaths and improving performance of individuals by affecting physical & mental growth. This has direct bearing on performance of society as a whole. What we see in terms of death is only tip of iceberg. Malnutrition is always attributed to lack of food. This is not true in this age group because the biggest source of nutrition is mother's milk which god bestows on every mother. Still, there are many myths & misconceptions in the mind of everyone including the health care workers as far as maternal & child nutrion is concerned. Some of the common ones are: 1) Myth: Pregnancy & Lactation are disease state: Hence, many patients ask for medicines. But, actually they are Natural, Physiological process. There may be diseases / Complications in few cases which may affect the outcome. Even LSCS babies can be fed on the OT table itself. Breastfeeding (BF) is “Natural”, “Tailor- made” for Baby & also “Species Specific” & “Gestation Specific”. 2) Myth: There is no need for ANC preparations: During last trimester of pregnancy, we should inform the mother about BF, counsel her, and build her confidence. Convince the family members that their support is important for successful lactation. 3) Myth: small breasts- inadequate milk Size of Breast is not related to milk secretion. Fatty tissue determines size while secretory/ glandular tissue is responsible for secretion which is hormone dependent. Somebody has rightly said that a pair of Mammary gland knows better than the pair of Cerebral Hemisphere how much milk should be produced. 4) Myth: BF destroys the figure/ shape of body: In fact, BF regains the figure; weight gained during pregnancy & fat stored is utilized during lactation. Actually it is the pregnancy that destroys figure. 5) Myth: Child is crying- Mother has less milk: There are thousands of reasons for crying; baby usually cry during night & sleep during day. The 23 AOP GUJARAT adequacy of secretion can be judged by frequency of urination, Weight gain etc. if less milk- feed more frequently with complete emptying of breast each time even in Twins/ Triplets. If required use Galactogogues. 6) Myth: Secretion varies from breast to breast: Size on two sides may be variable even in normal mother; secretion usually doesn't vary unless gross pathology or secretory tissue was removed surgically. 7) Myth: Powder milk is good since Drs have advised it: Unfortunately, most of us are “?? TOO BUSY??” not interested in Promoting, Supporting and Protecting BF. We are not motivated enough to establish the lactation before discharge from NICU. 8) Myth: Formula milk enriched with Minerals, Vitamins & other nutrients: There can't be a substitute to nature's gift; Mother's milk can't be synthesized in any Laboratory. 9) Myth: Protein Powder/ HMF are nourishing: Artificial food has no added benefits, it contains preservatives & they are costly. Hence, advise natural proteins- Pulses, Nuts, dry fruits, eggs, milk based diet etc. 10) Myth: Some water needed specially in summer months: There is no need even in summer; Formula/ Animal milk fed babies may need, we can give ORS if diarrhea. It is said that if babies needed water, the nature would have given every mother a 3rd Breast for secreting water. 11) Myth: Bottle feeding is easy & must: Bottle feeding is easy since any relative or maid can feed even during night hours, especially in working mothers and spillage is less. But, it results in nipple confusion, has no definite advantages & is detrimental for future health. 12) Myth: There are many contraindications for BF: There are very few contraindications that are relative & not absolute. Even in HIV/ AIDS, Tuberculosis we can give BF with specific treatment. 13) Myth: BF in public is body shaming: No, in fact BF in public is now a Mother- Child Right issue. 14) Myth: Mother should have dietary restrictions: There is no definite concept of hot & cold foods, allergic foods and pus forming foods. 15) Myth: MNC Products are Innovative & need of the hour: They are giving biased, unscientific, misguiding information like the claim of Omega 3 Fatty 24 AOP GUJARAT acids for optimal Brain growth & Cognitive function in their products. Some products may be there for specific metabolic disorders. But, overall the MNC are Breaking the Laws! Their representatives are visiting private maternity homes offering newborn care, 'snacks' & scientific meetings are sponsored. Health drink products claimed they were better for stamina building than regular chocolate drinks. But, these are misleading, & no study submitted to back the claims. 16) Myth: Some foods are “Magic Foods”: There are no foods which can be declared as magic foods. 17) Myth: Packaged food are tasty & healthy: The junk foods are more tasty because of extra sugar, salt and fatty contents. They contain Mono Sodium Glutamate (MSG) & lead more than the permissible limits. Wrong publicity amounts to malafide intentions & playing with health of kids & young people of country. 18) Myth: If celebrities are promoting- it must be good: Role of Media & Celebrities has always been biased, unscientific & not evidence based. Claims like; contents no fruits, contents added flavors, artificial sweeteners & admixture of Aspartame/Acesulfame potassium etc have not prevented their use even by modern/ educated parents. Unfortunately celebrity's unscientific, biased, mis-leading endorsement continues unabated. Overall' media need to be more responsive. Role of Government-What are the regulations: The Parliament enacted the bill Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992 (IMS Act) & amended in 2003, The Food Safety & Standards Act, 2006 and laws related to Junk foods. But, the loop-holes results in the violations of provisions of these laws. Role of our Colleagues & academic organizations: Look at coverage & potential to save babies: 1. One hour BF: 22% of all neonatal deaths 2. Exclusive BF: 15% of all child deaths 3. Use of “Junk / misbranded food” with “Exaggerated health claims” is increasing. We have the power to change! Better Use it!! Don't Get Mislead by Advertisements; be “A Empowered / Informed Mother/ health worker / Consumer”. No matter how long we have travelled in wrong direction, we can always turn around on the right path for the health of future generation. Conflict of Interests: None 25 AOP GUJARAT
26 AOP GUJARAT Neonatal Shock
Dr Urvi Sanghvi MD(Ped),DNB(Neonatology),FIN Anmol Newborn Care, Rajkot
Shock is a complex clinical syndrome characterized by sudden failure of the circulatory system to maintain adequate tissue and organ perfusion, leading to inadequate oxygen and nutrient substrate delivery to body tissues and compromised metabolic waste product removal. This result in cellular dysfunction, which may eventually lead to cell death. Shock is often initially reversible, but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction. It is important to recognize that hypotension, which is commonly used to define shock states in adults, is generally a late finding of shock in neonates. Premature and very low birth weight (VLBW) neonates are most vulnerable to shock. Around 20% of VLBW neonates admitted to the neonatal intensive care unit (NICU) become hypotensive. Early recognition and urgent effective management are crucial to successful outcomes. The main types of neonatal shock and their causes are: a) Hypovolemic shock caused by acute blood or fluid and electrolyte loss. i. antenatalhemorrhage (spotting during the third trimester, placenta previa, abruptio placenta, feto-maternal transfusion, twin-to twin transfusion, birth injuries, birth asphyxia or rupture of umbilical vessels, spleen or liver) ii. post-natal blood loss - iatrogenic, or secondary to disseminated intravascular coagulation or vitamin K deficiency iii. fluid and electrolyte loss in newborn secondary to gastrointestinal abnormalities, vomiting, diarrhea, congenital adrenal hyperplasia (salt loosing type), NEC, surgery, exudative skin loss. b) Cardiogenic shock caused by cardiomyopathy, myocardial ischemia, arrhythmias, and heart failure. Severe intra-partum asphyxia, Primary structural heart disease like: Hypoplastic left ventricle, tricuspid atresia, pulmonary atresia or arrhythmias, persistent pulmonary hypertension in newborn, or patent ductusarteriosus in
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premature infants. The four main clinical features of cardiogenic shock are tachycardia, tachypnea, hepatomegaly, and cardiomegaly. Other features are a heart murmur suggestive of tricuspid regurgitation, narrow pulse pressure, basal crackles, and decreased urine output. Peripheral edema and raised JVP are relatively uncommon in the neonate c) Distributive shock caused by sepsis, vasodilation, myocardial depression, or endothelial injury. d) Obstructive shock from tension pneumothorax or cardiac tamponade. e) Mixed Shock due to combination of above. Pathophysiology:
Oxygen Delivery to Tissues
Cardiac Output
Hemoglobin level, Rate
Blood O2 saturation Rhythm stroke volume
Airway Breathing FIO2 Preload Afterload Contractility
Oxygen delivery to the tissue is influenced by cardiac output and blood flow more than blood pressure. Systolic, diastolic and mean arterial blood pressure readings that are usually considered abnormal may not necessarily be pathological. Likewise, hypotension is not synonymous with shock but is a feature that is emergent in the later stages of shock. Breach in any of the above process leads to decreased oxygen delivery to tissues and Shock.
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HYPOVOLEMIC SEPTIC SHOCK CARDIOGENIC SHOCK SHOCK
THIRD SPACE VASODILATION MYOCARDIAL LOSSES DEPRESSION VENOUS RETURN CARDIAC (PRELOAD) CONTRACTILITY
LOW CARDIAC OUTPUT
NEUROHUMORAL COMPENSATION
- HEART RATE FAILURE OF COMPENSATION - CONTRACTILITY PERSISTENCE OF INSULT - VASOCONS TRICTION HYPOTENSION
MICROCIRCULATORY CHANGES POOR PERFUSION OF VITAL ORGANS
OXYGEN INABILITY TO UTILISE MAJOR ORGAN DELIVERY NUTRIENTS REMOVE DYSFUNCTION METABOLIC WASTE - RENAL FAILURE - CEREBRAL - ARDS SUBCELLULAR & CELLULAR INJURY - RELEASE OF PROTEOLYTIC ENZYMES AND TOXIC PRODUCTS
- DOWN REGULATION OF O2 METABOLISM (VO2) - FAILURE OF ENERGY (ATP) PRODUCTION - ACIDOSIS Clinical Features: The clinical parameters are produced by body compensatory mechanisms. 1) Conventional parameters used in standard practice: a) Capillary filling time b) Heart rate c) Urine output d) Blood pressure e) Presence of lactic acidosis f) Central venous pressure 29 AOP GUJARAT
g) Mixed venous saturation h) Arterio venous oxygen saturation 2) Newer parameters now used in clinical practice- a) Functional echocardiography b) Near infrared spectroscopy 3) Novel parameters under research a) Electrical cardiometer b) Visible light spectroscopy c) Perfusion index d) Functional cardiac MRI If shock progresses decompensatoryphase starts.Blood pressure falls; baby becomes dull,peripheral pulse not palpable. Severe oliguria,seizures,coma,hypoxia and metabolic acidosis herald an irreversible phase and terminally cardiac dysfunction and arrhythmia willoccur. Every attempt should be made to diagnose and treat shock in early stages. The severity can be assessed by scoring various parameters. S. No. Parameter 0 1 2 1. Skin Color Normal Pale Mottled 2. Skin turgor Normal Low Very Low 3. Skin termperature Normal Cool Cold 4. Periphral pulses Normal Weak Imperceptible 5. Arterial blood pressure Normal < 20% decrease > 20% decrease from from normal normal Mild Shock : Score of 1-3, Moderate Shock : Score of 4-6, Severe Shock : Score of 7-10 Factors that suggest irreversibility of shock are: a) Ongoing fluid/blood requirement despite control of hemorrhage b) Persistent hypotension despite restoration of intravascular volume c) No improvement in parameters (cardiac output/ blood pressure) despite inotropic support d) Futile cycle of uncorrectable hypothermia, hypo perfusion, acidosis, and coagulopathy Laboratory tests: 30 AOP GUJARAT
The following tests should be considered: a) Complete blood count b) Total and differential white blood cell counts for infection. Although both elevated WBC and low neutrophil counts can be predictive of neonatal sepsis, neutropenia is a better marker because of its greater specificity; few conditions other than sepsis and pre- eclampsia depress the neutrophil count of neonates10. When defining neutropenia, one needs to bear in mind that neutrophil counts vary depending on gestational age, type of delivery, site of sampling and even altitude. c) Coagulation tests for DIC, liver failure and hypocoagulability states. d) Electrolytes, BUN/creatinine and urinalysis e) Hepatic function tests to assess renal and liver function respectively. f) Chest x-ray, EKG g) Cardiac enzymes and echocardiogram h) If Obstructive shock- CT or V/Q scan (PE), echo (tamponade). i) An echocardiogram (heart ultrasound) or right heart (Swan-Ganz) catheterization may show low cardiac output (pumping action), confirming shock, and may also help to differentiate hypovolemic from cardiogenic shock j) Serum lactate - to gauge the degree of hypoperfusion k) Pro-inflammatory cytokines such as IL-18 a predictive marker that differentiates infected and non-infected neonates l) Increase in the chemokine IP-10 is a sensitive early marker of infection in neonates m) More invasive testing is often required: arterial blood gas for O2/pH; central venous oxygen measurement, systemic vascular resistance, and cardiac output may be measured through central venous catheters. n) If septic shock is suspected, blood, urine, umbilical or wound cultures are advocated with head ultrasound. The 2012 AAP clinical report recommends that LP be performed for an infant with any of the following clinical conditions: A positive blood culture Clinical findings that are highly suggestive of sepsis Laboratory data strongly suggestive of sepsis Worsening clinical status while on antibiotic therapy Functional echocardiography may help in adopting a physiology-based logical approach to 31 AOP GUJARAT treatment in infants with hypotension or shock – it may be used in choosing fluid resuscitation therapy or inotropic therapy, and further what type of inotrope or vasopressor therapy is indicated based upon preload, afterload and cardiac function on echocardiographic assessment
Cardiac Blood output pressure Situation
Normal/ Normal/ D A A High High Normal
Cardiac output Normal/ Compensated B Low High shock
Uncompensated C Low Low shock C B Normal/ Hyperdynamic D Low High circulation
Blood pressure Identification of the stage of shock by simultaneous measurement of cardiac output and blood pressure
Fast cardiac ultrasound (FoCUS)/focused echocardiography in shock Type of assessment Echocardiographic assessment Echocardiographic view(s) Qualitative assessment of cardiac Cardiac filling by "eyebaling" Apical 4 chambar view (A4C) and function and filling Assessment of inferior vena cava for collapsibility to assess hypovolemia parastemal long axis view (PLAX) Visual assessment of volume overloading Subcostal view Cardiac function assessment on visualization A4C and PLAX views Cardiac tamponade or pericardial effusion A4C and PLAX views Qualitative assessment of pulmonary • Hypertrophy and/or diatation of right ventricle Subcostal view, A4C, and PLAX views hypertension • Flattening of interventricular septum A4C and PLAX views • Right to left or bidirectional shunt across patent ductus arteriosus Parasternal short axis view (PSAX) • Bidirectional shunt across foramen ovale High left PSAX "ductal" view "Fast" quantitative assessment of • Assessment of pulmonary artery systolic pressure (PAP) Subcpstal view Pulmonary hypertension by assessing tricuspid valve regrgitation A4C view or modified PSAX • Right venricle to left ventricle (LV) ratio PSAX view • Eccentricity index PSAX view "Fast" quantitative assessment of • LV fraction shortening (FS%) PLAX view cardiac function • Tricuspid annular plane systolic excursion A4C view
32 AOP GUJARAT Goal oriented targeted management
Septic shock CHO Hypovolemia Respiratory PPHN or or pathology* Heart failure* Metabolic
ABC of rosusciution as por NLS / APIS guidelines; Intubau / ventilate Rule out and Rx pneumothorax. cardiac tamporude, hsPDA Normal MAP-CVP; ScvO2 >70%, Cl: 3.3-61/mVminor SVC flow >4Oml/kg/min Institute specific therapy as soon as possible AND early (functional) echo
Respiratory Pulmonary Prostagtandin E1 Fluid / blood support vasodilator- Echo specific Specific Antibiotics INO diagnosis therapy
Key to the management is early recognition and identifying the underlying pathophysiology of shock. The earlier findings include pallor, poor feeding, tachycardia, tachypnea, and temperature instability. As discussed earlier, hypotension is a late finding in neonatal shock. In addition, other late features may include weak peripheral pulses, low ScvO2, signs of decreased peripheral perfusion such as acidosis, elevated lactate. In spite of being a late finding, hypotension is the most commonly used determinant of decreased perfusion in NICU given the ease of monitoring. The clinician must keep a keen eye on the other signs of symptoms discussed earlier before the “ischemic threshold” is reached for low BP. The other traditionally used clinical parameters such as clinical assessment, HR, CRT, urine output, and serum lactate are also proxy indirect markers of cardiovascular well-being. The ACCM guidelines have established goals and therapeutic end points for the management of shock in both delivery room and subsequently in the NICU. The therapeutic end points in the first hour of resuscitation include CRT ≤ 2 s, normal and equal central and peripheral pulses, warm extremities, urine output >1 ml/kg/h, normal mental status, normal BP for age, normal glucose, and calcium concentrations Along with consideration of interventions to increase BP, attention should be paid to conditions contributing to hypoperfusion. These may include but not limited to patency of ductusarteriosus, sepsis, excessive mean airway pressure, pneumothorax, and adrenal 33 AOP GUJARAT insufficiency. These should be addressed accordingly. The common interventions used in NICU to improve BP include use of inotropes/vasopressors, volume resuscitation, and steroid administration. Hemodynamic effects Name of drug Dose Site of action Renal and mesenteric dotation Dopamine 1-4 µg/kg/min Dopaminergic receptors (1 and 2) Inotropic effects 4-10 µg/kg/min a receptors Vasoprossor, increase SVR and inaease PVR 11 -20 µg/kg/min b receptors Inotropic effects; decrease SVR; Dobutamine 5-20 µg/kg/min a1 and b2 receptors, some effect increase cardac output on a receptors Inotropic effects; decrease SVR Epinephrine (adrenaline) 0.02-0.3 µg/kg/min a1 receptors Vasopressor effects; increase SVR 0.3-1 µg/kg/min b1 and b2 receptors Vasopnesaor effects; increase SVR Nor-epineptrine 0.1-1 µg/kg/min a1 and a2 receptors (nor-adrenatine) Uncertain-enhance sensitivity to catechoiamines Hydrocortisone 1-2.5 µg/kg; 4-6 hourly Enhance sensitivity to catecholamines Increase SVR; no inotropic effect Vasopressin 0.018-0.12 U/kg/h Vasopressin 1 receptors Inodiator effects, lusitropic effects; increase Mirinone 50-75 µg/kg/min bolus followed by Phosphodiesterase III inhibitor and contractity; and decrease SVR 0.25-0.75 µg/kg/min produces effects at b1 and b2 receptors Inodilator effects; increase contractility without increasing Levosimendan 6-24 µg/kg/min bolus followed by Multiple action including Phosphodiesterase myocardid oxygen demand 0.1-0.4 µg/kg/min inhibrtor effect on higher doses Goal of cardiovascular treatment
Vasoconstriction Inotropy Vasodilation Phenylephrme Norepinephrine Epmephrme Norepinephrine Epinephrine Dobutamine Epmephrme Dopamine Isoprenaline Dopamine Dobutamine Milrinone Vasopressm Isoprenalme (Dopamine) Milrinone
Inotropy & Vasoconstriction Inotropy & Vasodilation Norepinephnne Dobutamine Epinephnne Isoprenaline Dopamine Milrinone Conclusion : Shock in the newborn period is associated with unique pathophysiologic states that need careful assessment and individualized approach for management. Early recognition of shock and its underlying pathophysiology is critical in instituting early target specific intervention, which may improve outcomes in patients with neonatal shock. A focused bedside functional echocardiography can provide vital anatomic and physiologic information to such management 34 AOP GUJARAT
Specialist in Treatment of
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35 AOP GUJARAT MEDICAL ERRORS IN NICU
Dr. Suman Rao PN MD, DM (Neo) Professor (Neonatology), St. John’s Medical College Hospital Consultant WHO, Dept of MCA, HQ, Geneva
A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. It is failure of a planned action to be completed as intended. The burden of medical errors is huge and the “adverse events “ we observe is only the tip of the iceberg. Medical errors are unfortunately so common that they are the third leading cause of death in the world.
Consequences of Medical errors
The medical errors can affect the patient in the form of increased morbidity ,hospital stay, further interventions for diagnosis and monitoring, financial and social stress and most serious forms can lead to death.
The patients are not the only victims of medical errors .Doctors also bear the brunt in the form of shame , isolation and the guilt of committing the error. Punitive actions due to the ME further leads to further financial and emotional stress to the doctors.It is important for the health care workers to remember that well intentioned individuals who care about their work, make the vast majority of errors. So its important to learn from the previous experiences and take steps to prevent it in the unit again.
Types of Medical Errors
Medical errors could be classified as diagnostic errors, treatment errors, and others;
¡ Errors of Commission
¡ Errors of Omission
¡ Active errors: error at level of caregiver
¡ Latent errors: errors of faulty design or system errors
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Categorisation of the impact of errors Classification Category Description No error A Circumstances or events that the capacity to cause error No harm B An error occurred but the error did not reach the patient C An error occurred that reached the patient but did not cause the patient harm
D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm Harm E An error occurred that may have contributed or resulted in temporary harm to the patient and required inervention F An error occurred that may have contributed or resulted in temporary harm to the patient and required initial or prolonged hospitalization G An error occurred that may have contributed or resulted in permanent patient harm H An error occurred that required intervention necessary to sustain life Death I An error occurred that may have contributed to or resulted in the patient's death
Not all the medical error lead to adverse event but it is very important to identify and address them as they can prevent future adverse events.
Medication Error
Medication errors constitute 80% of the medical errors. Neonates in NICU are more physiologically more prone for ME due to changing pharmacokinetics in neonates, weight based dosing, high use of off label drugs, lack of dosaage forms and concentrations for neonates and as they cannot communicate.Look alike-sound alike drugs are a major contributers for ME. The similar sounding drugs like epinephrine – ephedrine or lamotrigine- lamivudine are some of the many examples of similar sounding drugs.
A prospective observational study on Medical errors from our Institute involving 269 enrolled neonates showed that medical errors had occurred in 22% of the enrolled neonates, of which only 2% required interventions to rectify. Majority were due to omission (75%) involving oral syrups and wrong dosage (10%) . 14 % were detected before reaching the patients.The determinants of ME were NICU stay > 7 days, prescription of > 5 drugs, outborn status.
Diagnostic errors
A diagnosis that is missed, delayed or wrong is another important medical error 37 AOP GUJARAT
MISSED HARM NO MISSED OPPORTUNITIES (from delayed or OPPORTUNITIES wrong treatment/test) A B C D
Delayed/wrong Missed diagnosis Delayed/wrong Opportunities in associated with diagnosis but no Preventable diagnosis due to patient harm but no clear evidence of diagnostic harm system and/or clear evidence of missed cognitive factors missed opportunities opportunities
Disclosure of Medical Errors Communication between a health care provider and a patient, family members, or a patient's proxy that acknowledges the occurrence of an error, discusses what happened, and describes the link between the error and outcomes in a manner that is meaningful to the patient is vital . Disclosure of ME is not just the responsibility of the medical team but also an ethical obligation. It ensures better follow up , reduces the consequential harm and promotes a culture of safety. The added advantages of effective disclosure is the lesser likelihood of litigations.Hence its imperative to have a system for disclosure of medical error Prevention of Medical Errors Ways to address Medication Errors Simple ways are to avoid verbal orders, avoid abbreviations, writing orders in capitals to prevent misunderstanding The more difficult issue to address is look- alike drugs which require a more concentrated effort from the medical fraternity and pharmaceutical companies to bring some standardization in labelling and packaging. Strongest • Forcing functions • Standardization • Simplification of steps • Changing of the physical environment • Checklist, cognitive aids, and decision support • Reduce distractions • Redundancy or double-checks • Policy and procedure • Train or retain Weakest • Blame or reprimand 38 AOP GUJARAT
System Changes Medical errors should be addressed by “System changes” rather than individual punitive actions. The system can be modified in such a way that incorporates both better learning system and improved work culture. Learning system can be put in place by having continuous learning regarding ME, transparency and reliability and improved measurement of ME in the unit.Improved work culture can be brought about with effective leadership on top coupled with accountability , team work and transparency and psychological safety. . Some small system changes can make big changes. For example identification erros of neonates by mothers name or twins as 1 and 2 can be prevnted by double identification or identification by hospital number or by using barcodes. Introducing newer technology has also led to improvement in the rates of medical error. Electronic health record have become a standard across majority of public as well as private hospitals. Computer Provider Order Entry and Barcode Medication Administration have been used to effectively reduce the reduce the rates of medication procurement as well and dosage and administration errors. Smart infusion pumps have been used to effectively to administer drugs and prevent adverse event(AE) due to under/over dosage as well as AE due to rapid administration. Adequate man power is imperative to prevent medical errors. One study showed that the nurses handling more than 3 babies on a shift is 2.5 times more likely to commit a medical error. Another strategy to mitigate potential medical error is by giving a good hand over of the cases by the nursing staff as well as the doctors during shift changeover. Hand off of the patient to the next care giver should have accurate information about patient care,treatment and services. The ideal way to hand over the cases is using the I PASS the BATON technique (Introduction patient Assessment situation Safety Background Action Timing Ownership of care and Next plan) Finally it is important to create a culture of “psychological safety” so that health personnel can discuss of medical errors without fear of punitive action. Conclusions Across the global healthcare sector, MEs have been attributed to AEs, increased costs, and overall poor care delivery. Teamwork, education, and training through structured initiatives are required to improve patient safety. Accepting the contributions of team members, reducing barriers to reporting errors, and promoting a work environment where all individuals work together can have significant effect on improving patient and staff safety. To Err is Human ; But to admit and rectify it ,is superhuman. 39 AOP GUJARAT Photo Gallery
MoC Dr. Ashwini Shah & Dr. Akshat Khemka Welcome Address by President SPACT Dr Kirit Sisodiya Inaugration
Launching of E-GURUKUL by AOPG President Dr. Yogesh Parikh Dr. Digant Shastri Visiting the SPACT Office
Dr. Abhay Shah Dr. Bakul Parekh Dr. Sandip Trivedi
SPACT New Team SPACT Old Team Dr. Kanaksinh Surma & Dr. Chetan Shah
Book Release at PEDICON SPACT Best Branch Award at PEDICON IAP Rajkot Best Branch Award at PEDICON 40 AOP GUJARAT Photo Gallery COLORS GUJPEDICON District BNCRP TOT
Colors of Life - Hum Sath Sath Hain.. Colors of Life- Happiness Colors of Life - Satisfaction
Colors of Life - Family Colors of Life - Friendship Colors of Life - Extended Family
Colors of LIfe - Old is gold Colors of Life - Dance Colors of Life - Smile 41 AOP GUJARAT Photo Gallery COLORS GUJPEDICON ACADEMIC FEAST
42 AOP GUJARAT Photo Gallery
43 AOP GUJARAT E Gurukul Date : 24th January 2021 @ SPACT Hall, Sarsana Convention Center Complex, Surat Infectious Disease CME & SPACT Installation Ceremony Topic Speaker Interesting cases in Pediatric Infectious Disease Moderator : Dr. Darshan Chauhan Panel Discussion Panelist : Dr. Bakul Parekh Dr. Abhay Shah Dr. Kanaksinh Surma Rapid Diagnostic Test Dr. Digant Shastri Updates on PCV in India Dr. Abhay Shah Dr. Bipin Desai Oration Dr. Piyush Gupta, President, CIAP 2021 Novel Approach in typhoid Prevention : Dr. Chetan Shah A new Generation TCV Lessons learned from Clinical Career as Pediatrician Dr. Bakul Parekh Managing drug resistant infections in Practice Dr. Abhay Shah Practical learning Practical Pearls in RTI A case based Approach Moderator : Dr. Abhay Shah Panelist : Dr. Sandip Trivedi Dr. Diagnt Shastri Dr. Darshak Makadia Date : 30th - 31st January 2021 Common Issue and current perspectives in Dr. Indu Khosla Respiratory Medicine Dr. Pawan Kalyan Date : 13th February 2021 Common Issue and current perspectives in Neonatology Nutrition of Premies Dr. Umesh Vaidya Which Ionotrope and When? Dr. Anup Thakur Date : 14th February 2021 Common Issue and current perspectives in Neonatology Respiratory Distress in term Neonates Dr. Umesh Vaidya Common Errors in NICU Dr. Anup Thakur Neonatal Hypoglycemia...can be a Nightmare Dr. Ashish Mehta 44 AOP GUJARAT E Gurukul Topic Speaker Date : 21st February 2021 Common Pediatric Clinical Issues Crying Child Dr. Palaniraman Common cases with Practical Learning Points Dr. Tapisha Kumar Anemia Beyond Iron Deficiency Anemia Dr. Deepa Trivedi Ideal Timing for Surgical Intervention Dr. Amar Shah Date : 27th February 2021 PG Clinic Clinical Examination of Cardiovascular System Dr. Baldev Prajapati Date : 28th February 2021 Neurological Disorder in Children Acute neuromuscular Paralysis Dr. Lokesh Lingappa Autoimmune Encephalitis Dr. Mohammed Kunju What is not CP? Dr. Shefali Gulati Choice of Antiepileptic Drugs Moderator : Dr. Siddharth Shah Panelist Dr. Ritesh Shah Dr. Tarun Gondaliya Dr. Sarbani Raha Date : 6th March 2021 PG Clinic Clinical Examination of Central Nervous System Dr. Baldev Prajapati Date : 7th March 2021 Neurological Disorders in Children Movement Disorder Dr. Anoop Verma Ring Enchanging Lesions in Brain Dr. Arijit Chattopadhyay Recent Advances in Cerebral Palsy Dr. Sheffali Gulati Headache in Children Moderator : Dr. Vineet Wankhede Panel Discussion Panelist Dr. Anand Keshvan Dr. Nitish Vora Dr. Anita Sharma 45 AOP GUJARAT E Gurukul Topic Speaker Date : 14th March 2021 IYCF CME Juncs Guidelines Dr. Rekha Harish Myths And Misconceptions About Child Nutrition Dr. Satish Tiwari Complementary Feeding Dr. Mallikarjun Challenges And Solutions To Breast Feeding Related Moderator Dr. Ketan Bharadva Problems Dr. Kamlesh Parekh Panelists Dr. Parag Dagli Dr. Jayant Shah Dr. Rupal Dalal
Date : 20th March 2021 PG Clinic Clinical Examination of Alimentary System Dr. Baldev Prajapati
Date : 21st March 2021 IYCF CME Part 2 Adolescent Nutrition, Need of an Hour Dr. Hiral Naik Sub Impact of Iycf on Maternal Health, Child Health and Dr. Banapurmath National Development Causes and Solutions to Childhood Obesity Dr. Elizabeth Micronutrients in Health and Disease Moderator: Dr. Upendra Kinjawadekar Panelists : Dr. J P Dadhich Dr. Sanjay Prabhu Dr. Prarthana Kharod Patel Date : 27th March 2021 PG Clinic Clinical Case of Cardiovascular System Dr. Saumya Jhaveri
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47 AOP GUJARAT Yuva Mitra - Let's understand the feelings of teens... Yashvi Jignesh Parikh Class 10 Navrachana School Sama
Q.1Give your brief introduction. Tell me about your strengths and weakness. A.1 I am Yashvi Parikh and I am 16 years old. I have a penchant for reading books and I am a Bharatnatyam dancer. I am very sensitive towards others' feelings. I can find the silver lining in the grimmest of situations and am good at expressing my thoughts in the form of poems. I strongly believe in treating everyone with respect and I can't stand injustice. On the other hand, my fear of failure restrains me from taking risks or exploring new fields. Sometimes I lack the self control and end up breaking the rules I had set for myself, like restricting my screen time. Q.2 What are the challenges you are facing in your adolescent period? A.2 In my adolescent period, the greatest challenge I am facing is of frequent emotional disturbances. I often cry, laugh or angry over petty reasons and my emotions don't seem to be under my control. Sometimes I find it difficult to cope with such mood swings. I get very upset when things don't go the way I expected them to, especially with my friends. There are times when I feel lonely. I feel like there is nobody who understands me and my feelings. When I don't meet up to my expectations, start doubting myself and my capabilities. I often feel uncertain and indecisive when I think of my career and my future. Q.3 How you overcome that issues? A.3 I believe the best way to cope with emotional disturbances is to pen down all my thoughts at that moment. It makes me feel like I am talking to someone without being reacted to or judged. Towards the end of my write up, my thoughts become more sorted and I begin to calm down. Talking to my parents and friends about what I am going through is another way to overcome such challenges. They show me the brighter side of the situation, help me get through the problem and I feel cared for. Sometimes I like doing yoga, cycling around or taking a short break to drive my mind off the difficulties I am facing. In the end, we all know 48 AOP GUJARAT
that time is the best healer. It's important to give it all some time and to trust the process. Q.4How do you solve the conflicts with your parents? A.4 During my initial adolescent years I used to argue a lot with my parents. I felt they didn't understand me and always wanted to contradict my thoughts and ideas. From my clothes to my friends, they seemed to go against my decisions everywhere. In my opinion, the key to solve these conflicts is to communicate and spend quality time together. It took me some time but, slowly, I started to open up to my parents and understood their perspective. Initially it did seem uncomfortable and awkward but, once the rapport was built between us I voluntarily went up to them and talked about how I felt. We must remember even though they scold us and contradict our ideas, our parents love us unconditionally and they have our best interests in mind. Q.5 What were the challenges of e learning you faced and how you overcame it? A.5 E-learning, which was introduced this year due to the pandemic, was a new experience for all of us. Apart from the perks of using technology, I faced some challenges too. Sitting in front of the computer screen for 4-5 hours at a stretch often caused strain to the eyes. There were times when I was unable to convey my doubt to the teacher owing to certain technical glitches. Also it isn't easy for them as well, to listen to all students in the limited duration of each period. Besides, the usual issues were also encountered such as poor internet connectivity, glitches with the computer, latency etc. I overcame these challenges by taking help from my friends when I missed some classes due to internet issues. I used to call the teachers after school hours and get my doubts solved over the phone. While tackling these problems, I could also enhance my knowledge about computers and new technology. Q.6 Which is better e learning or classroom learning? And give reasons for the same. A.6 Undoubtedly, I would choose classroom learning over e-learning. Although e-learning saves a lot of time and paper, classroom learning stands superior to it in many other ways. In a classroom, students can have a face-to-face interaction with the teachers which, according to me, is more helpful in understanding the concepts. I usually have several doubts relating to different topics. I find it easier to get those solved in a classroom rather than calling up the teacher or asking during video-conference meetings. I believe
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classroom learning is more interactive and inclusive as all the students are involved in the discussion taking place with the teacher. To the contrary, in e-learning, often there are only a handful of students participating in the class activities. I would agree that a wide variety of resources are available on the internet for us to understand the concepts better. Videos, graphs and presentations can be used to explain the topics in interesting and easy ways. Also, there is no time constraint on the students to some extent. They can choose their own time to study. Thus, in my opinion, classroom learning combined with e-learning can be a great idea once the pandemic gets over. Since, I have always enjoyed interacting with the teachers and participating in classroom discussions, I would prefer classroom learning over e-learning. Q.7 What you want to become and why? A.7 I haven't chosen my career path in concrete terms yet. I want to pursue my career in the field of Science. I am considering medical as an option but am not quite sure about it. What I certainly know is that whatever I take up as my job would make me happy. I do not wish to be guided by money or fame while choosing my career. My aim is to bring about a positive difference in the lives of people through my work and to cure the world from mental illnesses. Q.8 Given a chance to change one thing in the world, what will you like to change? A.8 Given a chance, I wish to change the way women are treated in the society, especially in India. Even after 73 years of Independence, there are many households in India where the birth of a girl child is looked seen as a burden. Women are not guaranteed complete safety once they step out of the house. Sexual division of labour is very prominent where women are required to manage the household chores along with doing their jobs, while men must only work and earn money for the family. From the film industry to labour at the construction sites, women and men are not given equal treatment. Domestic violence still prevails in some parts of the world. Women do not receive the respect they give to their male counterparts. I want gender equality in the world, not only in principle but also in practice. The stigma around associating women with household work should be eradicated. Passing judgements over the dress up or behaviour of girls should stop. Every woman must receive the respect she deserves. 50 AOP GUJARAT
51 AOP GUJARAT Overweight & Obesity-Risk Factors & Solutions
Dr. Elizabeth K E. Ph D, MD, DCH, FIAP, FRCPCH (Lon.) Prof. & HOD, Pediatrics, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari Former Prof. & HOD, Pediatrics & Superintendent SAT Hospital, Govt. Medical College, Trivandrum Introduction The realization that mankind is sitting on the volcano of obesity and comorbidities is frightening. The COVID 19 pandemic has imposed restrictions on mankind and hence children and most adults are destined for prolonged homestay. Exogenous obesity is the most common type. The obesity pandemic, which was already alarming with 2% increase per year, is now found have hiked 10-20% in the current year. The concern regarding childhood obesity is that it is the forerunner of adulthood obesity. Obesity in the infant leads to 20% adulthood obesity, in the child to 40% and in the adolescent to 80% adulthood obesity. Obesity should be understood as a severe form of malnutrition with multiple deficiencies of micronutrients and antioxidants, and not as overnutrition. There are various risk factors that program a child to obesity. Most of these are modifiable within a window period of opportunity. 1. Low Birth Weight As per the Barker Hypothesis and evidence from Dutch Famine, Mysore, Delhi and other cohorts, fetal growth restriction (FGR), fuel deficiency and vascular stress in utero is found to program the baby to early onset of adulthood diseases like obesity, diabetes, hypertension, dyslipidemia, cardiovascular diseases, stroke and so on. This is referred by terms like,'fetal programming', 'early nutrition programming', 'fetal origin of adulthood diseases' and 'developmental origin of health and diseases'. Such fetuses tend to have Doppler abnormalities or persistently below 3rd percentile for growth. The changes are brought about via epigenetic mechanisms. Normal birth weight of around 3 kg is the greatest wealth of a baby, which has a protective role. 2. Large Birth Weight Large birth weight > 4 kg and macrosomia > 4.5 kg also program the baby to the metabolic syndrome route. This is often the result of maternal obesity, excess pregnancy weight gain
52 AOP GUJARAT more than expected for pre-pregnancy BMI (Table 1), gestational diabetes and so on.Preventing excess weight gain during pregnancy and LGA babies are equally important like addressing LWB.
Table 1. Institute of Medicine. Weight Gain During Pregnancy. National Academy Press,2009
BMI Weight (kg) Weight Gain 2 Weight Gain (kg) Heiaht (m ) (lbs)
Underweight 12.5 - 18.0 28 - 40 BMI < 18.5
Normal weight 11.5 - 16.0 25 - 35 BMI 19-24.9
Overweight 7.0 - 11.5 15 - 25 BMI 25-29.9
Obese 5.0 - 9.0 < 15 BMI > 30.0
3. Accelerated Postnatal Growth Rapid weight gain in early life, including rapid catch-up growth also program the baby towards metabolic syndrome. This is due to overfeeding, especially on obesogenic diets in the postnatal period. The Glyco- Macro-Proteins (GMPs) and the insulinogenic amino acid profile of bovine milk are known causes. The adverse changes may be visible as early as three years of age. Postnatal overgrowth should be monitored and prevented. 4. Suboptimum IYCF Practices Abrupt stoppage of breastfeeding, early introduction of bovine milk, introduction of cereals before 4 months of age are important risk factors. Breast milk has a protective role. Promoting optimum IYCF practices by anticipatory nutrition guidance can go a long way in prevention. 5. Nutrition Transition from Traditional 'Low Energy High Nutrient' Food to 'High Energy Low Nutrient' JUNCS. Ready to eat food has now become the rule rather the exception. The universal availability of
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JUNCS- High in fat, salt and sugar Junk foods, Ultra-processed, Nutritionally inappropriate, Caffeinated Carbonated Colored Cola drinks and Sugar sweetened beverages, the branded food chains with offers and celebrity adds coupled with high purchasing power and high expenditure on food have brought in the disaster. Traditional foods give 100 Kcals/ 100 g compared to 600-1200 kcals/100 g in these items. Behavioral Change Communication (BCC) among children, adolescents, and society, to restrict these items, except during celebrations, is expected to bring a change. 6. Consumerism, Industrialization, Globalization and Marketing Strategies Food industry has become a major profitable business. Marketing strategies are aimed to influence the consumers. This chain is difficult to break. Positive reforms like laws, taxation, banning toys attached to food items, and offering large portion sizes, safety measures to reduce trans-fat, sugar and salt content inbakery items,may be promising. 7. Lack of Growth Monitoring and Denial of Overweight/Obesity Tracking of BMI from birth and growth monitoring can serve as a screening as well as intervention tool. The ideal BMI at birth is 13, 17 at one year, reaching a nadir of 15 by 5-6 years and then slowly rising to 18.5- 22 by adulthood. The 'adiposity rebound' happening from the nadir can be a predictor, earlier the dip, more obesity and later the dip, more thinness. Denial of obesity is common, as mothers compare their children with other overweight children. BMI is not applicable to body builders and athletes. Waist circumference is recommended among Asians, who have central obesity. Growth monitoring and proper communication are recommended. 8. Environmental Factors Factors like changes in school timings, school transport system, school canteens, tuitions, extra classes, lack of play areas, lack of safety while playing out are causes of sedentary lifestyle leading to obesity. Missing breakfast and giving money instead of tiffin box have a negative impact. Banning Junk foods in schools is a welcome change. Obesity is more of an 'Environmental Shift', rather than a 'Genetic Shift.' 9. Changes in Behavioral and Social Norms & Parenting Choices Factors like higher purchasing power, food becoming the centre of all social gatherings and accepting mobile or TV screen as the new 'baby-sitters' for children have made a serious
54 AOP GUJARAT negative impact. The 5S: Sedentary Lifestyle, Screen addiction, Sleep deprivation, Smoking, lack of Sun exposure have emerged as key risk factors. Prolonged sitting is considered as the new smoking equivalent, especially in the COVID era. 10. Host/Genetic Factors This is not a major cause. Host factors like endocrine and metabolic causes account for 4% of cases and genetic syndromes like Prader Willy, Down Syndrome and monogenic conditions like Leptin deficiency account for 1% cases only. Recommendations Early identification and proactive measures for prevention can go a long way in reverting the current trend. Weight appropriate for height with a metabolically healthy profile, should the goal. The parameters of Metabolic syndrome should be disseminated for early screening and interventions; Waist Circumference >90th centile with any two of the following: BP >130/85, FBS >100, S. Triglyceride >150 and HDL cholesterol <40. Non-alcoholic Steato-hepatitis (NASH), renamed as ' Pediatric Fatty Liver Disease (PFLD), should also be considered. The motivation for exercise is said to reduce by 10% with every unit increase in BMI above normal. Hence, family intervention is advised. Dietary restriction, cutting down calories > 6 years of age, adopting a disciplined diet, favoring traditional items with plenty of raw vegetables and fruits, increasing physical activity, group exercises, ensuring adequate sleep, restricting screen time, smoking and prolonged sitting and ensuring adequate sun exposure are recommended. Promoting optimum IYCF practices and undertaking growth monitoring can go a long way. 108 can be a new mantra for the current era; 1 hour of exercise, 0 JUNCS and 8 hours sleep. 'The clock is Ticking' is the theme for Obesity Day 2021. Let us act now and save the future of the children.
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55 AOP GUJARAT COVID-19 Vaccines
Compiled by Dr Raju Shah Medical Director, Ankur Institute of Child health, Ahmedabad Former Professor & HOD, GCS Medical college, Ahmedabad Overview The genetic sequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was published on January 11, 2020, and the rapid emergence of research and collaboration among scientists and biopharmaceutical manufacturers followed. Various methods are used for vaccine discovery and manufacturing. As of March 18, 2021, The New York Times Coronavirus Vaccine Tracker lists 3 vaccines in emergency use in the United States. Several other vaccines are approved for full use (outside the United States) and 22 vaccines are in phase 3 clinical trials globally. [1] A number of antiviral medications and immunotherapies are also under investigation for coronavirus disease 2019 (COVID-19). Several technological methods (eg, DNA, RNA, inactivated, viral vector, protein subunit) are available for vaccine development. Vaccine attributes (eg, number of doses, speed of development, scalability) depend on the type of technological method employed. Some methods have been used in the development of previous vaccines, whereas others are newly developed. Available vaccines: BNT-162b2 (Pfizer): Overview • Genetic-code vaccine • Storage and shipping requirements: Frozen; ultra-cold storage of -70ºC • Requires reconstitution • Once thawed, stable while refrigerated for up to 5 days • Room temperature stability: 2 hours • Dose: 2 intramuscular injections in deltoid muscle 21 days apart BNT-152b2 (Pfizer) is a nucleoside-modified messenger RNA (modRNA) vaccine that encodes an optimized SARS-CoV-2 receptor-binding domain (RBD) antigen. 56 AOP GUJARAT
Vaccine efficacy was 95%, and no serious safety concerns were observed. The only grade 3 adverse event with a frequency of greater than 2% was fatigue at 3.8%; headache occurred in 2% of participants. Short-term mild-to-moderate pain at the injection site was the most commonly reported reaction, and severe pain occurred in less than 1% of participants across all age groups. The EUA was update in late February to allow short-term storage at temperatures more commonly found in typical pharmaceutical freezers. This new storage option could offer greater flexibility in managing and maintaining vaccine distribution and supply. mRNA-1273 (Moderna): Overview • Genetic-code vaccine • Dose: 2 injections 28days apart • No dilution required • Shipping and long-term storage: Frozen (-20°C) for 6 months • After thawing: Standard refrigerator temperatures (2-8°C) for 30 days • Room temperature: Up to 12 hours The mRNA-1273 vaccine (Moderna) encodes the S-2P antigen. The US phase 3 trial (COVE) launched on July 27, 2020. The trial was conducted in cooperation with the National Institute of Allergy and Infectious Diseases and included more than 30,000 participants who received two 100-mcg doses or matched placebo on days 1 and 29. Results showed an overall efficacy of 94.1% for the original viral strain. Immunogenicity data at 90 days after the second vaccination was evaluated in 34 participants in the phase 3 trial. A phase 2/3 trial in adolescents aged 12-17 years began in December 2020 and is expected to enroll 3,000 participants. Another phase 2/3 trial in children aged 6 months through 11 years launched in March 2021 with the goal of enrolling 6,800 participants. Booster vaccine Phase 2 trials have started to evaluate COVID-19 booster vaccine candidates. Booster vaccine mRNA-1273.351 encodes for the prefusion stabilized Spike protein of the SARS-CoV-2 variant B.1.351, first identified in the Republic of South Africa. mRNA-1273.211 is a multivalent candidate that combines mRAN-1273 ancestral strains and mRNA-1273.351 in a single 57 AOP GUJARAT vaccine. In parallel NIH will conduct a Phase 1 clinical trial to assess the monovalent and multivalent modified mRNA-1273 vaccines as a primary series in naïve individuals and as a booster vaccine in those previously vaccine with mRNA-1273. Ad26.COV2.S (ENSEMBLE): Overview • Viral vector vaccine • Shipping and long-term storage: Frozen (-20ºC) for up to 2 years • After thawing: Standard refrigerator temperatures (2-8ºC) for up to 3 months • Dose: 1 injection Interim results for the phase 1/2a trial describing neutralizing antibody titers of more than 90% at day 29 and 100% at day 57 were published in January 2021. The EMSEMBLE phase 3 trial results were released in late January 2021. Safety and efficacy data are based on 43,783 participants randomized 1:1 accruing 468 symptomatic cases of COVID-19. FDA analysis of the data at Day 28 determined the vaccine was 72% effective in the US, 61% in Latin America, and 64% in South Africa (where the B.1.351 variant was circulating) at preventing moderate-to-severe COVID-19 infection. Importantly, the vaccine was 85% effective in preventing severe disease in all geographic regions. Efficacy against severe disease increased over time with no cases in vaccinated participants reported after day 49. Additionally, the vaccine provided 100% protection against COVID-19 related hospitalization and death at Day 28. Additionally, Ad26.COV2.S showed consistent protection across race, age groups, including older adults (participants aged 60 years and older were 34.6% of the vaccine arm), and across all variants and regions studied, including South Africa where nearly all cases of COVID-19 (95%) were due to infection with a SARS-CoV-2 variant from the B.1.351 lineage. The EUA Fact Sheet for Health Care Professionals states efficacy of the vaccine in older study participants showed no overall differences in safety or efficacy compared with younger participants. At least 28 days post vaccination, efficacy against moderate to severe/critical disease at all study sites (ie, US, Latin America, South Africa) was 66.2% for those aged 60 years and older compared with 66.1% for those aged 18-59 years. In the United States, estimated
58 AOP GUJARAT efficacy was 85.9% at least 28 days after vaccination. NVX-CoV2373 (Novavax): Overview • Subunit vaccine • Dose: 2 injections, 21 days apart NVX-CoV2373 (Novavax) is engineered using recombinant nanoparticle technology from SARS-CoV-2 genetic sequence to generate full-length, prefusion spike (S) protein. This is combined with an adjuvant (Matrix-M). Results of preclinical studies showed that it binds efficiently with human receptors targeted by the virus. The phase 3 trial in the United Kingdom has completed enrollment and the phase 2b trial in South Africa have reported final results. UK phase 3 results: The study enrolled more than 15,000 adults aged 18-84 years, including 27% older than 65 years. • Calculated efficacy UK strain: 86.3% • Calculated efficacy original strain: 96.4% South Africa phase 2b results: This study enrolled over 4,400 patients beginning in August 2020, with COVID-19 cases counted from September through mid-January. During this time, the triple mutant variant, containing 3 critical mutations in the RBD and multiple mutations outside the RBD, was widely circulating in South Africa. • 55.4% efficacy for the prevention of mild, moderate, and severe COVID-19 disease was observed in the study population that was HIV-negative (N = 2,665) • 48.6% overall efficacy with results from both patient populations (ie, HIV positive and negative) • 100% protection against severe disease, including all hospitalization and death
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AZD-1222 (ChAdOx1 nCoV-19; AstraZeneca): Overview • Viral vector vaccine • Phase 3 trial was temporarily put on hold globally on September 6, 2020 after a study participant in the United Kingdom was diagnosed with transverse myelitis. After FDA review in the United States, phase 3 trials resumed there on October 23, 2020. • Storage: Refrigeration • Dose: 2 injections 28-days apart AZD-1222 (ChAdOx1 nCoV-19; AstraZeneca) is a replication-deficient chimpanzee adenoviral vector vaccine containing the surface glycoprotein antigen (spike protein) gene. This vaccine primes the immune system by eliciting antibodies to attack the SARS-CoV-2 virus if it later infects the body. Results of an interim analysis of the phase 3 clinical trial in the United Kingdom, Brazil, and South Africa are as follows: One dosing regimen (n = 2741) showed vaccine efficacy of 90% when given as a half dose, followed by a full dose at least 1 month later. Another dosing regimen (n = 8895) showed 62.1% efficacy when given as 2 full doses at least 1 month apart. The combined analysis from both dosing regimens (N = 11,636) resulted in an average efficacy of 70.4%. All results were statistically significant (p < .0001) In another trial, researchers studied the second vaccine dose administered at 3 months after the first dose instead of at 1 month. Outcomes showed no hospitalizations in the vaccine group after the initial 21-day exclusion period compared with 15 in the control group. Vaccine efficacy after a single standard dose of vaccine from day 22 to day 90 was 76%. Modelled analysis indicated that protection did not wane during the initial 3-month period. Similarly, antibody levels were maintained during this period with minimal waning by day 90. In the group that received 2 doses of the standard dose, vaccine efficacy was higher with a longer prime-boost interval (3 months) compared with an interval less than 6 weeks (82.4% vs 54.9% respectively). Additionally, nasal swabs were obtained from trial participants every week in the UK study, regardless of symptoms. This allowed assessment of the overall impact of the vaccine on risk of infection, and thus a surrogate for potential onward transmission. Analyses found a single standard dose of AZD-1222 reduced PCR positivity by 67%, and that, after the second dose, 60 AOP GUJARAT reduced PCR positivity by 49.5% overall. These data indicate that ChAdOx1 nCoV-19, used in the authorized schedules, may have a substantial impact on transmission by reducing the number of infected individuals in the population. COVAXIN: Overview COVAXIN®, India's indigenous COVID-19 vaccine by Bharat Biotech is developed in collaboration with the Indian Council of Medical Research (ICMR) - National Institute of Virology (NIV). Co-development with Ocugen announced for the US market. The indigenous, inactivated vaccine is developed and manufactured in Bharat Biotech's BSL-3 (Bio-Safety Level 3) high containment facility. The vaccine is developed using Whole-Virion Inactivated Vero Cell derived platform technology. Inactivated vaccines do not replicate and are therefore unlikely to revert and cause pathological effects. They contain dead virus, incapable of infecting people but still able to instruct the immune system to mount a defensive reaction against an infection. Received EUA in India in January 2021 following a fully enrolled phase 3 trial (n ~25,800). • It is a 2-dose vaccination regimen given 28 days apart. • It is a vaccine with no sub-zero storage, no reconstitution requirement, and ready to use liquid presentation in multi-dose vials, stable at 2-8oC. • A total of 25,800 subjects have been enrolled and randomized in a 1:1 ratio to receive the vaccine and control in a Event-Driven, randomized, double-blind, placebo-controlled, multicentre phase 3 study • Data from 25,800 participants, received vaccine or placebo in a 1:1 ratio showed that the vaccine candidate was well tolerated. COVAXIN demonstrated 81% interim efficacy in preventing COVID-19 in those without prior infection after the second dose. • Clinical trial to continue through to final analysis at 130 confirmed cases in order to gather further data and to evaluate the efficacy of COVAXIN in additional secondary study endpoints. Viral Variants and Vaccines: Mutations Viral mutations may naturally occur anywhere in the SARS-CoV-2 genome. Unlike the human 61 AOP GUJARAT
DNA genome, which is slow to mutate, RNA viruses are able to readily, and quickly, mutate. A mutation may alter the viral function (eg, enhance receptor binding), or may have no discernable function. A new virus variant emerges when the virus develops 1 or more mutations that differentiate it from the predominant virus variants circulating in a population. The CDC has launched a genomic surveillance dashboard. Researchers are studying how variants may or may not alter the extent of protection by available vaccines. Variants of concern: The CDC predicts the B.1.1.7 variant (first detected in the United Kingdom) will be the major circulating variant in the United States by March 2021. Enhanced genomic surveillance in some countries has detected other variants of concern (VOCs) including B.1.351 (501Y.V2) first detected in South Africa and the B.1.1.28 (renamed P.1) (501Y.V3) which was detected in 4 travelers from Brazil during routine screening at the Tokyo airport. A change of the B.1.1.7 variant that includes the E484K mutation (B.1.1.7+E484K) was discovered in early 2021 that furthers these concerns. The CDC is also tracking VOCs B.1.427 and B.1.429, which emerged in California. The immune response provoked by vaccines includes protection from the antigen by eliciting antibodies, T-cells, and interferons. Variants that have emerged in the United Kingdom and South Africa in late 2020 have multiple mutations in their S glycoproteins (ie, the spike protein), which are key targets of currently available vaccines. BNT162b2 vaccine: A two-thirds reduced neutralization of BNT162b2 vaccines against the B.1.351 variant was shown in vitro when compared with the reference viral strain. Other in vitro studies comparing sera of neutralizing antibody titers from participants in vaccine studies described use of sera from BNT162b2 SARS-CoV-2 vaccine showed no reduction in neutralization of pseudoviruses bearing the B.1.1.7 variant (ie, UK variant) and the B.1.351 variant (ie, South African variant). However, another study suggests that antibodies elicited by primary infection and by the BNT162b2 mRNA vaccine are likely to maintain protective efficacy against B.1.1.7 and most other variants, but that the partial resistance of virus with the B.1.351 spike protein could render some individuals less well protected, supporting a rationale for the development of modified vaccines containing the E484K mutation.
62 AOP GUJARAT mRNA-1273 vaccine: Similarly, the mRNA-1273 vaccine neutralizing capabilities were assessed against the UK and South African variants. No significant impact on neutralization against the B.1.1.7 variant was detected in the first phase of testing and reported in February 2021. In contrast, just a month later, decreased titers of neutralizing antibodies were observed against the P.1 variant, the B.1.427/B.1.429 variant (versions 1 and 2), the B.1.1.7+E484K variant, and the B.1.351 variant as well as a subset of its mutations in the RBD. A slight decreased neutralization is not considered to be clinically significant regarding vaccine efficacy, owing to the very high efficacy of each mRNA vaccine (ie, approximately 95%) to the Wuhan reference viral strain. In February, 2021, Moderna announced it is advancing its variant-specific vaccine candidate, mRNA-1273.351, against the B.1.351 variant first identified in South Africa into preclinical studies and a Phase 1 study in the United States. A multivalent booster candidate, mRNA- 1273.211, which combines mRNA-1273 and mRNA-1273.351 in a single vaccine and a third lower-dose of mRNA-1273 vaccine have also been forwarded to the National Institutes of Health for phase 1 clinical testing. NVX-CoV2373 vaccine: Novavax confirmed preliminary efficacy results for NVX-CoV2373 vaccine from the phase 3 trial in the UK (n > 15,000). The final analysis showed vaccine efficacy of 96.4% against the original strain of SARS-CoV-2. Final analysis from the Phase 2b trial (n > 4,400) conducted in South Africa for NVX-CoV2373 reported 55.4% efficacy among HIV-negative participants. The South African escape variant was the predominant variant (more than 90% of cases analyzed). Ad26.COV2.S vaccine: Johnson & Johnson reported phase 3 trial results (EMSEMBLE; n= 43,783) for their single-dose Ad26.COV2.S viral vector vaccine in late January 2021. The trial was conducted in geographical regions and during the time when several variants emerged. FDA analysis of the data at Day 28 determined the vaccine was 72% effective in the US, 61% in Latin America, and 64% in South Africa at preventing moderate-to-severe COVID-19 infection. Importantly, the vaccine was 85% effective in preventing severe disease and provided complete protection against COVID- related hospitalization and death in all geographic regions. Additionally, it showed consistent 63 AOP GUJARAT protection across all variants and regions studied, including South Africa where nearly all cases of COVID-19 (95%) were due to infection with a SARS-CoV-2 variant from the B.1.351 lineage. AZD-1222 (ChAdOx1 nCoV-19) vaccine: A study in the UK determine efficacy of AZD-1222 against the B.1.1.7 variant is similar to the efficacy of the vaccine against other lineages. Minimal protection against mild-to-moderate COVID-19 infection from the B.1.351 variant in South Africa was observed following 2 doses in non-HIV infected young adults (n ~2000) showing efficacy of 21.9%. These results prompted South Africa to halt roll out of the vaccine in early February. The SARS-CoV-2 vaccines currently authorized for use, and others that have late-stage clinical data available, are summarized in the Table 1:
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Other Investigational Vaccines: Additional vaccine candidates are in various stages of development and clinical testing. Examples of these vaccines are provided in Table 2. Table 2. Other Investigational Vaccines Vaccine Comments INO-4800 (Inovio Stable at room temperature for more than 1 y; frozen shipment Pharmaceuticals) not needed; interim results from phase 1 human trial (n = 40): favorable safety and immunogenicity; expanded to include DNA-based, 2-dose vaccine older participants. Phase 2/3 trial (INNOVATE) ongoing; phase 2 to evaluate 2-dose regimen (1 mg or 2 mg) vs placebo in 400 participants. Grant from Bill and Melinda Gates Foundation to speed testing and scale up a smart device (Cellectra 3PSP) for large-scale intradermal vaccine delivery; company has also received funds from the US Department of Defense. CVnCoV (CureVac) Phase 2b/3 trial (HERALD) was initiated in December 2020 of mRNA, 2-dose vaccine mRNA 12-mcg dose (2 doses on days 1 and 29) in multiple European and Latin American sites with goal of 35,000 participants enrolled. Partnering with Bayer, GlaxoSmithKline, and Novartis for production. Recombinant protein Randomized, double-blind, multi-center dose finding study adjuvanted vaccine (Sanofi conducted in adults aged 18 years of age and older to evaluate and GSK)\ the safety, reactogenicity, and immunogenicity of 2 injections given 21 days apart. The trial will include equal numbers of adults aged 18-59 years and those aged 60 years and older. Study initiated Q1 2021 plans to refine antigen formulation to achieve optimal immune response in older adults.Previous phase 1/2 study showed lower immune response in adults, likely owing to insufficient concentration of antigen. CpG 1018 adjuvanted Phase 2/3 trial of Clover's protein-based S-Trimer COVID-19 vaccine (Clover and subunit vaccine adjuvanted with Dynavax's CpG 1018 plus alum Dynavax) planned for early 2021. UB-612 multitope peptide- Comprised of SARS-CoV-2 amino acid sequences of the based vaccine (COVAXX receptor binding domain; further formulated with designer Th 65 AOP GUJARAT
Vaccine Comments [United Biomedical, Inc]) and CTL epitope peptides derived from the S2 subunit, membrane, and nucleoprotein regions of SARS-CoV-2 structural proteins for induction of memory recall, T-cell activation, and effector functions against SARS-CoV-2. Starting phase 2 trial in Taiwan and phase 2/3 trial in Brazil in Q1 2021. Covaxx is merging with its sister company (United Neuroscience) to form a new company call Vaxinity to include both companies' vaccine platforms. HaloVax (Hoth Collaboration with the Vaccine and Immunotherapy Center at Therapeutics; Voltron Massachusetts General Hospital; use of VaxCelerate self- Therapeutics) assembling vaccine platform offers 1 fixed immune adjuvant and 1 variable immune target to allow rapid development. Nanoparticle SARS-CoV-2 Vaccine prototype development utilizing self-assembling vaccine (Ufovax) protein nanoparticle (1c-SapNP) vaccine platform technology. PDA0203 (PDS Combines Medicago's recombinant coronavirus virus-like Biotechnology Corp) particles (rCoVLP) with GSK's adjuvant system. Phase 3 trial CoVLP (Medicago and initiated in March 2021 with goal of enrolling 30,000 Glaxo Smith Kline) participants initially in healthy adults aged 18-65 y, followed by individuals aged 65 y and older with comorbidities. The trial will take place in 10 countries, initially starting in Canada and the US. Recombinant adenovirus Approved in China and Saudi Arabia; preliminary data: 86% type-5-vectored vaccine efficacy; phase 2 trial: seroconversion of neutralizing antibodies (Ad5-vectored vaccine; seen in 59% and 47% of those in 2-dose groups; seroconversion Sinopharm [China]) of binding antibody seen in 96-97% of participants; Positive specific T-cell responses seen in 88-90% of participants. CoronaVac (Ad5-vectored Limited use in China. Interim phase 3 efficacy reports vary vaccine; Sinovac [China]) widely from several trials. A trial in Brazil reports efficacy of 50- 90%. However, a Turkish trial reports 91.25% efficacy (n = 7,371; data analysis based on 1322 participants – 752 vaccine and 570 placebo).
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Vaccine Comments rAd26 (frozen) and rAd5 Approved in Russia. Each vaccine vector carries gene for full- vector-based (lyophilized) length SARS-CoV-2 glycoprotein S. The phase 3 trial formulations (Sputnik V; administered 2 doses 21 days apart (rAd26 then rAd5) assigned Moscow Gamaleya in a 3:1 ratio of vaccine (n = 16,501) or placebo (n = 5,476). Institute) Interim analysis of results 21-days after the first dose (ie, day of dose 2) showed confirm COVID-19 infection in 0.1% of the vaccine group compared with 1.3% of the placebo group translating to 91.3% efficacy. hAd5 T-cell (Immunity Bio Phase 1 trial ongoing; vaccine targets inner nucleocapsid (N) and NantKwest) and outer spike (S) protein, which have been engineered to activate T cells and antibodies against SARS-CoV-2, respectively. These dual constructs offer the possibility for the vaccine candidate to provide durable, long-term cell-mediated immunity with potent antibody stimulation to patients against both the S and N proteins. MRT5500 (Sanofi and Phase 1 trial expanded to include the initial SC prime vaccine Translate Bio) with a room-temperature oral or sublingual booster to induce comprehensive immune protection and generate both systemic and mucosal antibodies. AG0302-COVID19 (AnGes mRNA-based vaccine candidate; preclinical evaluation and Brickell Biotech) demonstrated favorable ability to elicit neutralizing antibodies using a 2-dose schedule administered 3 wk apart in Fall 2020. Despite this, Sanofi announced the vaccine will not be ready to start clinical trials until second half of 2021 and it could be of use at a later stage against variants. EPV-CoV-19 (EpiVax) Adjuvanted DNA vaccine in phase 1/2 study in Japan; data readouts expected in Q1 2021; intent to follow with phase 3 trials in United States and South America. Discontiniued vaccine Subunit, T-cell epitope-directed vaccine. Preclinical validation development studies completed. Clinical trial anticipated in early 2021. Vaccine candidates V590 V590 and V591 (subunit vaccines): Phase 1 studies showed and V591 (Merck) immune responses were inferior to natural infection and those reported for other SARS-CoV-2 vaccines. 67 AOP GUJARAT
Noninjectable Investigational Vaccines Routes of vaccine administration other than injection are also undergoing development as shown in Table 3. Table 3. Noninjectable Investigational Vaccines Noninjectable Vaccine Comments hAd5 T-cell (ImmunityBio Vaccine targets inner nucleocapsid (N) and outer spike (S) and NantKwest) protein, which have been engineered to activate T cells and antibodies against SARS-CoV-2, respectively. Phase 1 trial expanded to include the initial SC prime vaccine with a room-temperature oral or sublingual booster to induce comprehensive immune protection and generate both systemic and mucosal antibodies. Intranasal COVID-19 Phase 1 dose-ranging study of 1 or 2 intranasal doses initiated in vaccine (AdCOVID; February 2021. The trial will evaluate safety and Altimmune, Inc) immunogenicity in up to 180 participants aged 18-55 years. ChAdOx1 nCov-19 inhaled Dose-ranging trial for orally inhaled vaccine beginning phase 1 (University of Oxford) trials in 30 volunteers in Fall 2020. saRNA inhaled (Imperial Dose-ranging trial for orally inhaled vaccine beginning phase 1 College of London) trials in 30 volunteers in Fall 2020. VXA-CoV2-1 oral vaccine Recombinant adenovirus vector type 5 (Ad5) expressing (Vaxart) coronavirus antigen and a toll-like receptor 3 (TLR3) agonist as an adjuvant. Preliminary phase 1 trial (n = 495) showed induced CD8 T-cell responses to the viral spike protein. Neutralizing antibodies not detected in most subjects. Company is evaluating optimal dosing schedule in order to assess efficacy in phase 2 trials. PittCoVacc (University of Vaccine candidate using transdermal microneedle for COVID- Pittsburgh School of 19; testing in mice produced antibodies over a 2-wk period; Medicine) microneedles are made of sugar, making it easy to mass- produce and store without refrigeration. MV-014-212 (Meissa Intranasal live attenuated vaccine. Generates both mucosal IgA Vaccines) antibodies in nasal cavity and systemically circulating antibodies. The company created the SARS-CoV-2 intranasal vaccine using their existing RSV vaccine platform. Phase 1 dose- escalating study announced in March 2021. 68 AOP GUJARAT
COVID-19 Vaccination While Pregnant or Lactating:
The Centers for Disease Control and Prevention (CDC) states that pregnant women are at an increased risk for severe illness from coronavirus disease 2019 (COVID-19) and death, compared with nonpregnant individuals. In addition, pregnant women may be at increased risk for other adverse outcomes (eg, preterm delivery). The CDC has issued Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines, which discusses the limited data available regarding administration to pregnant women. Owing to these risks, preventing severe COVID- 19 infection is essential for both mother and fetus.
The American College of Obstetricians and Gynecologists (ACOG) has issued guidelines regarding vaccination of pregnant and lactating patients against COVID-19. Key points from these guidelines are as follows:
Do not withhold COVID-19 vaccines from pregnant women who meet criteria for vaccination according to the priority groups recommended by the CDC's Advisory Committee on Immunization Practices(ACIP).
COVID-19 vaccines should be offered to lactating individuals on the same basis as they are offered to nonlactating individuals when lactating individuals meet criteria for vaccination based on ACIP-outlined prioritization groups.
Individuals considering COVID-19 vaccination should have access to information about vaccine safety and efficacy, including information about data that are not available. A conversation between the patient and the clinical team providing care may assist with decisions regarding the use of vaccines approved by the FDA under emergency use authorization for the prevention of COVID-19 in pregnant patients. Important considerations include:
• Level of viral activity in the community
• Potential efficacy of the vaccine
• Risk and potential severity of maternal disease, including the effects of disease on the fetus and newborn
• Safety of the vaccine for the pregnant patient and fetus
69 AOP GUJARAT Anemia Beyond Iron Deficiency Anemia
Dr. Deepa Trivedi Pediatric Hematologist-Oncologist Hematology-Oncology Clinic, Vedant, Ahmedabad Program Director- CIMS-Sankalp BMT unit Anemia is a serious public health problem in our country- often related to under –nutrition, poverty and poor dietary intake of iron rich food. It is often seen in pregnant women, infants, young children and adolescents. 7 out of every 10 children aged 6-59 months in India have anemia. 3% have severe anemia, 40% have moderate and 26% are mildly anemia.- mostly nutritional – iron or /B12 and Folic acid deficiency or both- There are other rare causes of anemia in children- We will be discussing etiology of non iron deficiency anemia. Basics of Anemia- Hemoglobin is relative to age and sex of patient. So we must be familiar with what's normal for specific ages. 1. Preterm 2. Term 3. 1-10 yrs 4. >10yrs
NORMAL HEMOGLOBIN VALUES FOR FULL-TERM AND PREMATURE INFANTS FULL TERM PREMATURE g/dl of Blood g/dl of Blood Birth 19.3 Slightly less than Full Term 0.5 Months 16.6 15.4 1 Month 13.9 11.6 Age at Hemoglobin Nadir 9-12 weeks 6-10 weeks Mean Hemoglobin at Nadir 11.2 9.4 4 Months 12.2 11.7 6 Months 12.5 12.4
Normal Age Normal MCV (fL) Hemoglobin (g/dL) Birth 14 - 20 100 - 130 0.5 - 1 year 11 - 13 70 - 85 1 - 4 years 11 - 13 70 - 85 4 years - puberty 11 - 13 75 - 90 pubertal female 12 - 16 80 - 100 pubertal male 14 - 18 80 - 100 70 AOP GUJARAT
HISTORY – a detailed history is very important 1. Diet- BF/Top and complementary feeds. In older children – milk and milk products consumption, junk food , fruits and vegetables in diet and intake of dal/protein . 2. Family history/ Siblings 3. Transfusion in past 4. Medicines including anticonvulsants/AKT/ Ayurvedic and homeopathy. 5. Remember Heavy metal poisoning ( LEAD)- with herbal medicines . 6. PICA- iron def/ lead poisoning 7. Worm infestation 8. GI issues- constipation/diarrhea. 9. Celiac disease/Malbsorption /duodenal atresia/ NICU graduates/ NEC. WORKUP- 1. Height and weight/BMI/BSA 2. Physical exam- conjunctiva/tongue/nails/ lymph nodes/liver and spleen size. 3. First CBC- must include Reticulocyte count and indices- 4. Hemoglobin 5. MCV- <70 vs 70-90, >90- microcytic ,normocytic or macrocytic 6. RBC count 7. WBC/ Platelet count- one line down or bi or pan cytopenia. MENTZER INDEX---- very important not to miss Thalassemia minors in the community-proper counseling and family screening required to prevent each and every Thalassemia major birth. Ÿ Thalassemia minor may have normal hemoglobin and might be missed unless we see MCV and number of RBC in million. Ÿ Thal minor- very low MCV<60 with RBC high- >5 million. Ÿ MCV/ RBC in million Ÿ The Mentzer index - highest sensitivity (98.7%), specificity (82.3%) to differentiate between IDA and Thalassemia trait.
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Interpretation- Ratio > 13 Fe Deficiency , < 13 Suggests Thalassemia minor. CAVEAT- must be iron replete- or there can be FALSE NEGATIVE. MACROCYTIC ANEMIA This is the second most common cause of anemia after IDA in the community. Ÿ LDH/Coombs Test/ B12 and Folate Ÿ In Macrocytic anemia- MCV >100- Ÿ Increased Hemolysis – High LDH, and bilirubin-indirect elevated. Ÿ History- Mother deficient/ complementary feed poor Ÿ No milk or milk product Ÿ Junk food in adolescents Ÿ p/s- macrocytosis/ Hyper segmented neutrophils/
Macrocytes/ovalocytes/ hypersegmented neutrophil Common causes of anemia- • 0-3 months- • Physiological- anemia nadir • Pathological- Hemolysis- ABORH/ Blood loss/TORCH/ congenital hemolytic anemias- G6PD/ HS • 3-6 months- • Hemoglobinopathy • Nutritional • > 6 months- • Nutrional- IDA/B12/Folate • Sex – • X linked – Males- G6PD/ XL Sideroblastic Anemia Females- adolescents- Heavy Menorrhagia- think about VWD Microcytic Hypochromic Anemia- other than IDA
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Interesting case- • 2 year old girl from Sabarkantha came to the Ahmedabad with the history of recurrent anemia in June 2018. • Past history not significant. • First PCV is given on 21st march 2018. • Family history : Not significant • General examination: Pallor • No Organomegaly. • CVS : Tachycardia
Biochemistry Outside Investigations
20/03/2018 20/03/2018 22/03/2018 23/03/2018 13/06/2018 S. Iron 57 TIBC Hb 3.9 7.2 8.8 2.1 S. Ferritin TLC 29300 12600 11300 23300 S. Bilirubin 0.7/0.3/0.4 S. LDH Differential count 47/49/02/02 54/41/02/03 45/50/02/03 45/51/01/03
Sickling test was done on 21/03/2018 : Platelets 1100000 511000 450000 948000 Negative MCV 47.8 59.5 65.8 44.3 Vitamin B12 was done on 21/03/2018 : 162
• 15/6/2018 • Hb – 2.5 gm%, TLC – 18300/cmm, Platelet count – 225000/cu mm. • Differential count: Polymorphs-35%, Lymphocytes-61%, Eosinophils-01%, Monocytes- 02%, Basophils-01% • MCV – 54.9 fl. • Reticulocyte count – 2.1%, Corrected retic count – 0.5%. • Peripheral smear: Hypochromic microcytic blood picture • Iron /TIBC/Ferritin/ B12 and LDH all WNL. • Bone marrow exam with trephine biopsy done. • D/D- • sideroblastic anemia • CDA- congenital dyserythropoetic anemia • IRIDA- iron refractory iron deficiency anemia • lead poisoning. 73 AOP GUJARAT
Bone marrow - FINAL DIAGNOSIS- Sideroblastic Anemia.
LOW POWER HIGH POWER IRON STAIN – iron laden cell seen Sideroblastic Anemia- Ÿ Congenital sideroblastic anemia o X-linked sideroblastic anemia: This is the most common congenital cause of sideroblastic anemia and involves a defect in ALAS2.Although X-linked, approximately one third of patients are women due to skewed X-inactivation (lyonizations). o Autosomal recessive sideroblastic anemia involves mutations in the SLC25A38 gene.- this form usually has severe anemia. o Genetic syndromes: Rarely, sideroblastic anemia may be part of a congenital syndrome – associated with ataxia, myopathy, and pancreatic insufficiency ŸAcquired clonal sideroblastic anemia o Clonal sideroblastic anemias – part of myelodysplastic syndromes (MDS). Mostly seen in Adults. Ÿ Acquired reversible sideroblastic anemia o Causes include excessive alcohol use (the most common cause of sideroblastic anemia), pyridoxine deficiency , lead poisoning and copper deficiency. o Antimicrobials that may lead to sideroblastic anemia include isoniazid, chloramphenicol, linezolid, etc. CDA- congenital dyserythropoetic anemia- Types of CDA: type I, type II, and type III. CDA type I - moderate to severe anemia. It is AR – CDAN1 gene defect. It is usually diagnosed in childhood or adolescence. May be associated with skeletal abnormalities in toes or fingers. CDA type II – AR- SEC23 B gene defect- can range from mild to severe- associated with jaundice, hepatosplenomegaly, and gallstones. Usually diagnosed in adolescence or early adulthood- often associated with iron overload and heart disease, diabetes, and cirrhosis. 74 AOP GUJARAT
CDA type III - tend to be milder. AD. Related to 15q22 gene. IRIDA • IDA- HB of less than 11-12 and ferritin below 15 with MCV < 65 and MCH <20. • Refractory iron- lack of HB rise by 1 gm/dl in 4 weeks with proper iron/compliance and no GI issues. IRIDA- iron refractory iron deficiency anemia. • Variable degree of microcytic hypochromic indices • Low-normal to normal serum ferritin • Very low serum iron and transferrin saturation (TSAT) • Inappropriately high serum hepcidin levels compared to degree of anemia • Oral iron refractoriness as per standard criteria for evaluation of response to oral iron • Presence of homozygous or compound heterozygous mutation in TMPRSS6 gene. • Onset of anemia which is mild-moderate degree in infancy or early childhood • Presence of history of anemia in other siblings or an elder sibling being chronically treated for iron deficiency without much improvement. • Very low MCV and MCH- compared to degree of anemia. • Mild or no HS Megaly. • Stigmata of classical iron deficiency like hair changes, dry skin, koilonychia and angular cheilitis. • High RBC count and low reticulocyte count. • IDA- usually low RBC and low Retic count.
Rare inherited Iron-related anemias Gene affected Defects of iron transport/uptake Hyportransferrinemia TF DMT 1 mutations STEAP3 mutations SLC1 1A2 Defect of iron absorption STEAP3 IRIDA Defects of iron recycling TMPRSS Aceruloplasminemia Defects of erythroid mitochondrial iron utilization CP X-linked sideroblastic anaemia ALAS2 X-linked sideroblastic anaemia/ataxia ABCB7 AR-sideroblastic anaemia SLC25A38 AR-sideroblastic anaemia GLRX5 75 AOP GUJARAT Common Office Problems of Lower Extremity in Children Dr. Ashima Choudhry Sahetia M.S.(Ortho) Banglore Pediatric Orthopaedic Surgeon Fellowship in Pediatric Orthopaedics – Mumbai, Pune, Seoul (South Korea) Abstract: Assessment of lower limb problems require a thorough understanding of the evolution of lower limb alignment throughout growth. Physiologic alignment at one age may be pathological at another age. Physical examination includes observing the gait, assessment of total and segmental limb length, joint alignment, stability and motion. Imaging evaluation begins with radiography of the affected limb also sometimes comparison films of contralateral side are also required specially if it's a unilateral disorder. Conditions affecting the lower limbs can be congenital, developmental or acquired. Treatments includes observation, reassuring the parents, bracing, casting or surgical interventions including guided growth, acute or gradual correction of angular, rotational or limb-length discrepancy. Introduction: Lower extremity conditions are a frequent reason for office visits and include a wide range of physiologic and pathologic presentations. Understanding growth-related changes and age- appropriate differences is key to distinguishing these presentations. Rotational and angular differences can be evaluated clinically and radiologically(Fig.1). Although rotational differences are usually physiological, angular deformities more frequently are pathological. Congenital tibial bowing can be self-resolving or can be indicative of an underlying abnormality of pseudarthrosis of tibia. Lower Extremity Disorders Rotational Alignment The rotational profile of the lower limb evolves from birth to approximately 10 years of age after which very little change is expected in lower limb rotational alignment. Anteversion of femoral neck relative to the shaft of the femur is highest at birth which gradually reduces to 15 degrees. Anteversion can contribute to intoeing gait. Tibial torsion is the most common cause of an intoeing or out-toeing gait in children. As no effective non-surgical treatment is available for physiological rotational differences, observation accompanied by thorough parental 76 AOP GUJARAT
education and reassurance is the primary management strategy. Derotation osteotomy for persistent and symptomatic deformity can be performed using open or percutaneous techniques. While planning surgical correction in these children, CT rotational profile is of utmost importance for evaluating the exact amount of derotation which is required. Miserable malalignment syndrome is a rotational difference which is unlikely to resolve without treatment. It can be a primary cause of anterior knee pain caused by patellar maltracking. Most rotational differences resolve throughout growth. Rotational profile should be considered when evaluating a patient with patellofemoral pain. In severe cases, miserable malignment syndrome is treated with femoral and tibial derotational osteotomies. Fig 1. Illustrations show parameters for evaluating rotational and angular differences. Fig1A, The measurement of mechanical axis deviation (MAD), Lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA) and lateral distal tibial angle (LDTA). JLCA = joint line congruity angle. Fig1B, Measurement of posterior proximal tibial angle is shown. (Cited from Gordon JE, Dobbs MB: Lower extremity and foot and ankle disorders)
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Genu Valgum
Physiological genu valgum starts around 2 years of age and peaks at 4 years of age with subsequent straightening of the leg towards an adult alignment of 5- 7 degrees of valgus which is usually achieved by the age of 8 years (Fig 2). Etiologies of pathological genu valgum are rickets, skeletal dysplasia, renal osteodystrophy, osteochondromas, physeal injuries, fibular hemimelia, proximal metaphyseal tibial fracture or fibrous dysplasia. Addressing any modifiable underlying etiology is important, and regular observation allows timely intervention. In children, with open physis, guided growth is the preferred treatment but close follow up is required to avoid overcorrection. Guided growth can be successful in the presence of abnormal physis also, although it may need to be instituted earlier than if the physis were normal because of the slower velocity of correction. Osteotomy of distal femur or proximal tibia is required for symptomatic valgus after physeal closure.
Fig 2. Graph illustrates the development of tibiofemoral angle in children during growth. The darker line represents the general trend. Salenius P, Vankka E: The development of the tibiofemoral angle in children. J Bone Joint Surg Am 1975;57(2):259-261.
Genu Varum
Tibia vara or Blounts disease is a developmental deformity of the proximal tibia involving the posteromedial physis and results in varus, procurvatum and internal tibial torsion with limb shortening. Onset around 4 years is considered as infantile or early onset type of disease, whereas, onset after age 10 years is considered late onset tibia vara. In late onset tibia vara usually, there is an element of distal femoral varus.
Infantile or Early onset tibia vara can be differentiated from physiological genu varum by progressive genu varum beyond the age of 18 months and is unilateral or asymmetrical in approximately 50% of patients. Radiologically, characteristic changes such as beaking or physeal widening occur in proximal tibial physis. The metaphyseal-diaphyseal angle is useful and reliable in distinguishing early onset tibia vara from physiological genu varum (Fig. 3). MRI may show thickening of the medial meniscus and other intra-articular compensatory changes. Spontaneous resolution can be seen in the early stages and unloading of the medial compartment can be done by bracing. As child with more advanced disease approaches 4 78 AOP GUJARAT years of age treatment options are gradual or acute correction using guided growth techniques or osteotomy. Guided growth has been successful in patients with early onset tibia vara with careful attention to the degree of deformity and the years of growth remaining. Physiological age must be considered in planning as patients with tibia vara are shown to have advanced skeletal maturity.
In older age of onset, associated with obesity in late onset tibia vara bracing or non-surgical management don't play a role. Child with higher body mass index and more severe deformities have been shown to be predictive for implant failure in growth modulation. Osteotomy correction for these children can be acute or gradual and one should consider distal femur varus deformity.
Fig 3. Illustration depicts metaphyseal-diaphyseal angle. Angles greater than or equal to 16 degrees strongly suggest Blounts disease.(Adapted from Birch JG: Blount disease. J Am AcadOrthop Surg 2013; 21(7):408-418.
FEED BACK Feed backs, suggestions, comments, queries and criticisms are always welcome. Please share important news, or clinical case which will be of help to everyone. : Please do write us : Dr. Prashant Kariya Email ID : [email protected] Whatsapp and SMS 98986 31283
79 AOP GUJARAT RECENT ADVANCES IN CEREBRAL PALSY Sheffali Gulati#, Sayoni Roy Chowdhury* #Coordinator, DM Paediatric Neurology Programme Faculty in-Charge, Center of Excellence & Advanced Research on Childhood Neurodevelopmental disorders Chief, Child Neurology Division, Department of Pediatrics All India Institute of Medical Sciences, New Delhi, India www.pedneuroaiims.org,[email protected]; [email protected] *DM Pediatric Neurology resident Center of Excellence & Advanced Research on Childhood Neurodevelopmental disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences New Delhi, India Background Cerebral palsy (CP) is a group of permanent disorders affecting the development of movement and posture, resulting in activity limitation, which is attributed to the non-progressive disturbances that occurred in the developing fetal or infant brain. Cerebral palsy is the leading cause of childhood disabilities with an estimated pooled prevalence of 2.95 cases per 1000 children in India. The precise cause remains uncertain in approximately 80% of cases; however, a dynamic interplay between several prenatal, perinatal and genetic risk factors has been the most widely accepted causal pathway to CP. A child with cerebral palsy faces tremendous lifetime challenges such as intellectual disability, epilepsy, behavioural concerns, sensory impairment, musculoskeletal problems, and sleep disorders. Early prediction and timely neuro intervention are imperative for an optimum functional outcome in those children. Prediction tools A diagnosis of CP is not well established until children reach the age of 1 to 2 years. Recent research has supported an early prediction model using a combination of standardized tools for neurological assessment (HINE, Hammersmith Infant Neurological examination), motor assessment (Prechtl Qualitative Assessment of General Movements), and neuroimaging (MRI) in accordance with the clinical history to identify infants at risk for CP as early as 5 months of age (Refer to Table1). Besides prognostication, HINE also offers objective information on the severity and motor topography of CP. HINE scores of less than 40 and less than 50 in high risk infants between 3 to 6 months of age are predictive of non-ambulant CP and bilateral CP respectively. Table 1: Early Prediction tools for CP (4) Age Predictive tools < 5 months— Standardized motor assessment: Prechtl Qualitative Assessment of General Movements (95%-98% sensitive) &Term-age MRI (80-90% sensitive) — Combined diagnostic accuracy of General movements assessment and MRI > 95%
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> 5 months— Standardized neurological assessment: HINE (90% sensitive), MRI (86-89% sensitive) & standardized motor assessment: Developmental Assessment of Young Children (89% sensitive) — Combined diagnostic accuracy of HINE and neonatal MRI > 90 Advances in Neuroimaging techniques Researchers have been able to identify specific neuroanatomical correlates for hand, language, and cognitive functions using advanced imaging techniques such as diffusion tensor imaging (DTI) and functional MRI (fMRI). A reduced hand function in children with CP corresponds to reduced fractional anisotropy (FA) in DTI, a marker of altered white matter integrity in distinct areas such as transcallosal motor fibres, thalamus, basal ganglia, and contralateral tracts (5). Advancements in neuroimaging, thus provide an adjunct to functional outcome measures as well as attempts to assess the impact of rehabilitation interventions. Advancements in Rehabilitation In the past decade, there has been a rapid surge in the use of technology-based interventions in the field of neuro-rehabilitation in cerebral palsy. Technology can play a vital role in facilitating mobility, optimizing communication, and enhancing self-care in children with CP. Robotics: Robotics can be identified as a branch of technology integrating robots with computer systems to simulate complex human actions. Robots can perform high-quality, supervised movements while also providing joint support and real-time feedback. Functional classification of mobility robots is based on the tasks they enable to achieve. Gait training robots (for example Lokomat, NF walker) involve the integration of grounded exoskeletons with limited body weight supported training and enhance gait kinetics, tolerance, and motor skills in ambulant CP children. The most frequently studied upper extremity robotic platforms are the Armeo-spring and You-grabber systems (6-8). Personal use robots may assist older children, especially those with limited upper extremity function. The most popular designs in this group are surface- mounted devices or autonomous systems with navigation capabilities. Self-care robots will, for example, pour water from a bottle, spoon food into one's mouth, etc. (9). Social robots on the other hand can help users by engaging them in social interactions such as helping in conducting therapy sessions by inspiring quotes and instructions by physical demonstration of exercises (10). Neuromuscular stimulation aided walking technology Multichannel neuromuscular stimulation-assisted gait trainingfacilitates the appropriate 81 AOP GUJARAT activation of lower-limb muscles via the use of wearable-wireless surface electrodes to achieve a more functional gait pattern (11). Similarly, Walk-Aide The system is a self-contained device designed specifically to provide effective transcutaneous stimulation to the peroneal nerve to improve dorsiflexion of the ankle during the swing phase of gait eliminating foot drop and normalizing the gait pattern in children with hemiplegic cerebral palsy (12). Virtual reality technologies for sensorimotor training Virtual reality systems use interactive, real-time simulations to enhance multi-sensory feedback with the help of a user-computer interface. It allows the user to perform guided repetitive movements by replicating a real-life task. Most studies suggest that VR had a major impact on gait and balance rehabilitation in children with CP (13). Augmentative and alternative communication systems (AAC) Communication aide designs can range from manual signs and graphic symbols to more complex devices that synthesize speech. These AAC devices especially benefit non-ambulant CP children who have communication difficulties too. Eye-tracking or eye gaze control devices enables computers to know exactly where the user is fixing his gaze byvirtue of an infrared measurement system(14). These can be combined with speech-generating devices for providing communication opportunities. Another AAC device with passive input is the Brain- computer interface (BCI), which acquires brain signals, analyzes them, and translates this information into commands that are relayed to communication devices (15). Brain stimulation can also play a role in remedying CP. Transcranial magnetic stimulation (TMS) and direct brain stimulation are among non-invasive novel therapeutic approaches that reported satisfying results across various studies for the treatment of cerebral stroke, spasticity, and patients with hemiplegic cerebral palsy (16). The drooling scarf is another form of textile-based innovation for CP children. There has also been rapid advancement in the development of mobile applications that meet the health care needs of children with cerebral palsy. Apps such as Crazy copy games, See Touch Learn, iComm, etc.can guide users/caregivers regarding motor and cognitive training. Conclusion Early diagnosis and prompt neuro intervention with early stimulation form the cornerstone of the management of CP. Assistive technological innovations like AI-based Robotics, Virtual reality, Augmentative and alternative communication devices and mobile applications have shown promising results in providing a structured rehabilitation strategy for children with cerebral palsy. 82 AOP GUJARAT Knowledge Is Power- Knowledgeable Citizen is a Powerful Citizen
Dr. Sanjeev Goel
Be a Knowledgeable Citizen Introduction As the Greek philosopher, Heraclitus, said: “change is the only constant.” Well, Heraclitus would have been amazed if he were able to look around today. Change is not only changing constantly but is changing fast. Whether it is daily dose of new information about Covid, or it is about ever changing laws of the land which we need to keep updated about. Latest being the fire safety norms which has set all the medical fraternity on fire. There is another saying “Ignorance is bliss” which originates in Thomas Gray's poem “Ode on a Distant Prospect of Eton College” (1742). Many people would view this as a flaw or a hindrance. There isn't a person on this planet who knows everything. The fact that one is aware enough to recognize their own ignorance gives them an immediate advantage. A lack of knowledge in any field can be a fantastic catalyst for learning Ignorance of the law is no excuse in any country. If it were, the laws would lose their effect, because it can always be pretended. We have started a series of Infonars “Ignorance in no longer Bliss” through the digital platform of Computer and Medical Informatics Chapter of the IAP with an aim of imparting digital knowledge to the IAPians all over the country. Here in our own bulletin of Academy of Pediatrics, Gujarat. I would try to share some of the important information which we can use on day today basis. I plan to write a short article every one or 2 months. A. Have you turned Fifty or about to turn Fifty? Renew your Driving License 1. Do not forget to renew your driving license. The validity of the driving expires when you turn 50. The license has to be renewed every 5 years thereafter a. The license is valid up-to one month after the expiry date and application can be made before one month of the expiry date (your 50th birthday) b. The renewal process is very simple. NO NEED TO GO TO AN AGENT. Visit the 83 AOP GUJARAT
ParivahanSarathi website or click on the below link and take the appointment by paying the required fees. https://sarathi.parivahan.gov.in/sarathiservice/dlServicesDet.do 2. Other services which you can avail online with your Driving License. (For those who are far off from 50) a. Change of name and address and other services: Driving license is one document which we all carry at all times with us(If we do not then we must). This photo id can be used at almost all the places as photo id and address proof. With digital records it is important that our names must match at all places. Using the above link you can do the following online i. Updating address ii. Change in name iii.Issue of duplicate driving licence iv. Issuing international driving license v. Change of date in birth PLEASE BE INFORMED THAT YOU CAN HAVE A SOFT COPY OF THE DRIVING LICENSE AND MANY OTHER IMPORTANT DOCUMENTS IN DIGILOCKER, THE APP WHICH YOU CAN DOWNLOAD ON YOUR MOBILE B. Are you still carrying the old fragile Aadhar Card? Get a PVC Smart Aadhar Card now 1. Are you aware that you can get a PVC Aadhar Card online by just applying online with one OTP and paying Rs. 50. And LO, the New Smart Aadhar card having QR code too will be delivered to your door step in less than a week. Click on link https://residentpvc.uidai.gov.in/order-pvcreprint i. Click on the above link ii. Enter your Aaadhar card number iii. Enter OTP Pay online (Rs. 50)
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1. Other services which you can order online for Aadhar : Visit https://uidai.gov.in/ Registered Mobile number is necessary to avail these services i. Change of address ii. Download soft copy of Aadhar card iii. Link Aadhar to PAN and Bank via the banking login iv. Lock and unlock biometrics. v. Retrieve the Aadhar number in case you have forgotten vi. Create a virtual Aadhar number vii. Change date of birth and name online by self helphttps://ssup.uidai.gov.in/ssup/ Please download the mAadhaar app where you can have your soft copy of Aadhar card which is now accepted at airports, and other places C. Is your data in Permanent Account Number(PAN) matching with your Aadhar and Bank Update PAN details by visiting website https://www.onlineservices.nsdl.com/paam/endUserRegisterContact.html It is of utmost importance that you have exactly the same names in your PAN, Aadhar, Passport, Driving Licence, Bank accounts. Some people have names like Sanjeev, Sanjeevkumar, Sanjeevbhai, Sanjiv in different places. 1. Most of the websites are interlinked now. If you want to get a PAN card online, you don't even have to submit a photo as you have the option that your photo and other details can be picked up from the Aadhar card. 2. You need exactly the same spelling in PAN and Aadhar to verify income tax returns and to link PAN with Aadhar 3. You can visit the above website and do the following a. Change your name b. Change address c. Change date of birth d. Apply for duplicate PAN Again you can download the Digilocker app and store all your documents in the apps Dear friends, however we may want to interact with humans for our needs, the future will be governed by artificial intelligence. Already your first point of contact with banks, mobile companies, insurance companies is automatic systems and not humans. It's time that we keep ourselves updated. Best of learning and gaining knowledge For any queries please feel free to contact me on [email protected] or ping me on 9825265114 85 AOP GUJARAT Travelogue : North East India
Dr Kamlesh Parekh
During early March of 2019, we visited NE India (Assam, Arunachal & Meghalaya) out of 7 sisters -Assam, Arunachal Pradesh, Meghalaya, Manipur, Mizoram, Tripura & Nagaland); Sikkim is considered as the only brother. Planning: Choose 1) Duration of your vacation; 2) Destinations of interest: (Snow peaks/birding -Arunachal; Wild life -Kaziranga; Adventure tourism-Moderate tracking / Tented camping / Kayaking Meghalaya, Majuli for Eco tourism ; Hill station -Shillong….or a mixed bag? 3) Season to be discussed later. Our 19 D/N route consisted of Surat- N.Delhi-Jorhat -Gibbon Sanctuary-Majuli-Kaziranga- Nameri-Tawang-Guwahati-Dawki-Cherrapunjee -Shillong then flight Guwahati-Surat.
How to arrange the trip? A) Through a travel agent for fixed / tailor made trip. B) Do it yourself: Book flights for Guwahati / hotels /vehicle thro' booking websites. (a) Drivers in NE may be rough in behavior. (b) Even for 4 persons, Innova or similar vehicles are
86 AOP GUJARAT the best @ around 5,000 Rs a day, inclusive of everything. (c) As they don't deal in'per km' rates, you need to confirm exact route and itineraries before the deal. Our driver Idul Ahmed was good and can be contacted @ 09706223499 / 09101954016. (d) Don't worry about vegetarian food options en route. (e) Time zone is IST, Sun rises 01:40 hours earlier -say at 4:30AM and sets 5:00 PM. So start early. Assam : Not a hill station Assam is a river bed of Brahmaputra that connects all the other North- eastern states. The capital of Assam is Dispur, andis inside the Guwahati limits! We covered only 5 destinations of Assam: Guwahati, Kaziranga National Park (NP), Nameri NP, Jorhat (Gibbon Sanctuary) & Majuli Island. Guwahati best thing to do (a) One hour sunset boat-cruise ride on Brahmaputra (4 pm better than sundowner 5.30pm @ 350-400 Rs PP or dinner 7.30pm @1,300 Rs PP),munching some snacks/drinks (Alfresco Grand 09435558001 / 9854958549 @ www.alfrescogrand.com); (b) visit Maa Kamakhya Shakti Pith, renowned tantric temple of deity Sati – famous/infamous for sacrifices of goat esp. during Ambubachi Mela in June & Durga Puja;(c) Shopping -Assamese dress material or saree at Fancy bazaar or Paan Bazaar. (d) Other places of interest include Sankardev Kalashetra, Science museum, Temples (Basistha, Balaji & Umanandain the middle of the river).Bird lovers enjoyDeepor Beel(lake) on the way to airport. Where to stayat Guwahati? Accommodation is costly. e.g. Vivanta, Ginger, Radisson, etc. But, Hotel Nandan in the city is good (though overpriced). Westayed for 2 nights, as per Dr. Digant Shastri's recommendation at lovely, birding paradise, Brahmaputra Jungle Resort(09706099373 @Biplab), 1 hourfrom Guwahati / airport. One horned rhinofameKaziranga N.P.is one of the best wild life parks in India. Minimum 2 night's stay is must at this lovely national park. Jeep safaris(6am to 2pm, 3500/4500 vehicle 6pax, 2 hours duration) 3 regions: Central-Kohora, Western-Bagori, Eastern-Agoratoli (esp. water birds) Burapahar is Optional. Elephant safari1 hour duration (western region - Indian tourist, 900 Rs PP @ 5.30 & 6.30 am, booking on previous day). All hotels arrange safaris. Online safari booking @ https://www.kaziranganationalpark-india.com/info/Jeep-Safari.html. We did 5.30am elephant safari in western range then central jeep safari @8 am, took lunch and eastern safari @ 1.30pm. We had gala time of wild life viewing during the 2 days..
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Kaziranga Orchid /Cactus biodiversity Park/Museum& Changmai Shal Restaurant 9678413409 for original big Assamese thali veg n Non veg 200/250Rs. Cultural show at this cultural center include Folk – Bihu –Bamboo- Sattriya dances in the evening (6.30 to 8.0 pm) is a must. Book to & fro taxi for 3 km journey & take a seat early for best experience. Where to stay?High end resorts: Iora resort, Wild grass, Bonhabi, Diphlu River lodge, Infinity, Jupuri Ghar etc. We stayed at moderately priced Assam Tourism's Aranya Tourist Lodge. (08638082835 [email protected]). Food: Hornbill restaurant is worth trying. Best time to visit Assam is between 1st November to 31 March to avoid rains and visit Kaziranga NP. Shoulder season: October &April-May ok. Avoid Durga Puja time for NE states. Nameri NP: On way to Tawang from Guwahati (5 Hr.) or from Kaziranga (2.5 Hr.) after crossing mighty Kolia Bhomora Setu @ Tezpur, we have to choose between Bhalukpong and Nameri for a night or two stay. We preferred Nameri, along the Kameng aka Jia Bhoreli River, where one can opt for birding, slow river rafting, and trekking. River rafting closes at 1.30pm. Stay at Jia Bhoreli Wild Resort (08011159372, 09859547605) or Nameri Eco Camp(09678219052). Mājuli: World'sprobably biggest inhabited deltaic -River Island ofBrahmaputrais the abode of the Assamese Neo-Vaishnavite culture propagated by Sri Sankardev. Jorhat ferry takes 1/1.5 hours. Attractions: a) Eco-tourism, birding & lovely sunset views, b) Visit various Satras (Vaishnavite Monasteries e.g. Kamalabari Satra, Garamur, Auniati & Dakshinapath),c) Mask making & weaving art by Mishing tribe (Indo-Mongolian tribe cum Vaishnavites who follow Lord Krishna and Sun-Moon, too); d) Dance watching at the Satras daily / during festivals Call 09577228797 [email protected]. Stay of 2 days is recommended for soaking in the pristine nature @ La Maison de Ananda bamboo stilt cottages 08638156750 or @Ygdrasill bamboo cottage, both at very cheap price @booking.com. Best time to visit Majuli is Raas Utsav on Kartik Purnima (mid-November), when the entire district is transformed in to drama, street skits, dances and performances related to religious deities. One can avoid Gibbon WLS(famous for only Gibbon sighting in India near Jorhat),& Majuli, if pressed for time. Arunachal Pradesh (AP):Ideally, it requires 7 nights for western Arunachal Pradesh-Tawang. 88 AOP GUJARAT
One needs Inner Line Permit for entering AR. Obtaining eILP is very easy from arunachalilp.com. One needs id proof & a photo. Helicopter service being unreliable, we travelled by road. We stayed total 8 nights @Nameri National Park nearBhalukpong, Dirang, Tawang for 3/4 nights including Zemithang Valley & returnvia Bomdilla &Eagle Nest Bird Sanctuary (ENBS). Ziro, Along, Mechuka, Pasighat or Dibrang valleycould not be covered. Tippi Orchidarium on way to Dirang (1560 meters) &huge Dirang Monastery visit recommended. Stay @Hotel Pemaling, www.welcomeheritagehotels.com, [email protected] (08258919962). Visit or Stay @Letro home stay(09402072027 / 08794668634)Sangti valley, (13 km-40 min) a place known for migratory Black Necked Crane and serene river bed. Tawang: The winding roads amidst pine trees and then snow laden trees, snow-capped Himalayan peaks and the ultimate Se La (Sela Pass) makes the tour of Tawang a must. After passing Se La we paid homageto Jaswant Sinh Rawat& Indian soldiers who laid their lives during 1962 Indo-China war @Jaswant Garh memorial. Tasty bataka wada, samosa, momos, vada-idli at very cheap price withfree elaichi tea are offered by Indian soldiers at the canteen that boosted our spirit in wake of mounting high altitude sickness-headache, vomiting etc. at near 4100 meters (13,600 feet). Visiting Light & Sound Show @ War Memorial at 5.30 pm / in English at 6.30 pm evoked another bout of patriotism. Special permit – Restricted Area Permit (RAP) from district magistrate office for Bum La (China Border) and Koyla famed Madhuri Lake (Shungester Tso) was sought through hotel. And then we went forlocal sight-seeing that included giant Buddha statue, Tawang Monastery (largest monastery in India & 2nd largest in world after Potala palace in Lhasa), Pangateng Tso (PTTso Lake) &Nagu La Lake. Urjeling Gompa may be avoided. Next day, due to bad weather permit, RAP was not granted. So, we missed not only Bum La & Madhuri Lake, butMomo, Maggi etc. at 'Y' junction café as well. We visitedZemithang valleysituated on the banks of Nyamjang Chhu(Chhu=river)and GorsamGompa (one of the largest Stupa of India) via Tara Devi statue famed Lum La &after passing few water falls esp. BTK falls. We stayed at highly recommendable Mon Paradise hotel 09436825931 / 08794044998 Returning from Tawang, we visited awesome 100 meter highNuranang (aka Bong Bong Falls) (Jang) water falls. We stopped at army canteen of Jaswant Garh Memorial for hot tea, snacks &
89 AOP GUJARAT shopping of Cap & shawl. Se La Lakewas frozen and we were mesmerized and spellbound. We got a life time best, thrilling snow fall during the entire descent. Bomdilla @ 2400 meters, has view points and 2 monasteries that can be skipped. Eagle Nest Bird Sanctuary: It is one of the birder's paradise. We stayed at costly tented camps @Lama &then @Bompu villages of Kameng range (AE Travel 09911336281 / 09999030436 Gaurav at [email protected]). For going to ENBS, we have to take a detour from the NH13 at Tenga market and change vehicle to Sumo. For 2 days (reminding Majuli), we were out of civilized world due lack of electricity/phone connections. We had good sightings of birds, indeed @ ENBS. Best time to visit Arunachal: November or February end (to avoid rain and landslides). Meghalaya, a small state sandwiched between Assam and Bangladesh in the Patkai range (East Khasi, Garo and West Jaintia hill ranges),though lacks charm of snow peaked towering Himalayan ranges, is known to be abode of clouds & rains. “AtithiDevoBhav” attitude of Khasi people is noteworthy. From Brahmaputra Jungle Resort, we started in the morning towards Dawki via Shillong. After one hour, we stopped atJiva Veg Restaurant, 03638232032,a must stop for wonderful breakfastnear Nongpoh. Pretty women behind small stalls were selling pineapples and bananas, honey and pickles in bottles.Never miss a chance to eat pineapples-they are so sweet n tasty in Meghalaya. Umiam aka Barapani Lake with water sport facilities,situated 17 kms before Shillong may be avoided. While going to Shillong, just grab the photo opportunity and enjoy the makkai or pineapple on way at viewing spots that overlook the Umiam Lake. In Khasi, the elements of worship are water and rock. Thus many names have - Um (water), Maw (stone/rock) & Wah (water fall). After Shillong, we crossed Y junction and continued south east towards West Jaintia hills for Jowai and then Dawki. On the way 1) Mawlynnong, “the cleanest village in Asia” is just OK. We felt that we were walking in a good resort surrounded by trees and huts on super clean roads. One can do some shopping or have some snacks or can climb a 85 feet sky view tower, a vantage attraction for a view of surrounding lush green terrain & distant low lying Bangladesh plains or visit Balancing rock, nearby.One can stay in any of nearby homestays. 2) TwoKms from Mawlynnong is Riwai village, well known for a typical living root bridge. Hanging on a river, a
90 AOP GUJARAT typical bridge is made by people connecting the aerial roots of one massive rubber tree with that of another over 15/20 years. These bridges are 150- 200 years old and just gets stronger over time. We enjoyed local (black) berries and pineapple, etc. being sold on the long way towards the bridge. 3) Krang Shuri water falls near Jowai should be better visited during monsoon only. 4) India-Bangladesh Border: One can cross the border and walk into Bangladesh. Friendly atmosphere. We ate murmura and yummy berries. The last stop 5) Shnongpdeng, near Dawki village is a beautiful place on the banks of transparent Umngot river. We preferred staying at tented camps on the river bed itself rather than at Halatong & other home stays. It was an out of world - a lifetime experience for us. Boat riding in this “transparent” river was amazing. One can do kayaking or swimming and have camp fire or star gazing in a completely silent world. (09049442647/09856006437 Jesson & 08132079703 Adrian @ [email protected].) Cherrapunjee: Also known as Sohra, the wettest place on the earth. (Now the title rests with nearby Mawsynram). Don't expect rain in non-monsoon season and so no great waterfalls. Attractions: a) Water falls: Nohkalikai, Seven sisters (Nohsngithiang) falls, Wah Kaba falls, Dainthlen, Kynrem & other falls; b) Limestone caves: Arwah caves (best, 3km walk), Mawsmai caves and Garden of Caves; Eco Park opposite to seven sisters' falls is best avoided. c) We avoided tough trek of (4000 steps down)Double Decker Living Roots Bridge at Nongriat. d) Good veg food at Orange roots, near Ram Krishna Mission. Stay:One can day visit Cherrapunjee from Shillong or stay for a day.Kutmadan resort 08730945471 has got max likes on the net. Breakfast or even stay at the café Cherrapunjee 07085589227 almost midway between Shillong and Cherra is recommended. Shillong: Distancedat 2.5 to 3 hours (100 Km)from Guwahation beautiful NH37, this British hill station/Scotland of India or the abode of the cloudslies @ 1525 meters altitude. Attractions: a) Deity Shillong or Lei Shillong is worshipped at the Shillong Peak, 10 kms from Shillong@1,965 metres and commands a panoramic view of the Shillong valley. Beware of rush, start early to reach well before 3.30pm to this restricted air force area (closed on Wednesday). We enjoyed munching berries, pineapple, and murmura-bhel after photo shooting wearing Khasi costumes &telescope viewing. b) Elephant falls (3 steps), Huge Don- Bosco museum (closed on Sunday), ML 05 (military café), Air force museum, Ward's Lake for a leisurely stroll or boating. c) Mawphlang Sacred forest, 25 km from Shillong is worth a visit. The monolithic stones that served as animal sacrifice places in ancient times draws our attention as 91 AOP GUJARAT we enter the forest during a guided short trek of 45 minutes through Rudraksh & many other lush green trees. One can't take anything out or carry in to the sacred forest as per local belief! d) Avoidable: Lady Hydari park, Shillong cathedral & Botanical garden / shopping at Bara bazaar or police bazaar. Stay at Shillong is most costly. Kaizun B & B 03642502523 / 08794664730 @ www.kaizun.com, where we stayed is highly recommended &is value for money. Best time to visit Meghalayais in Monsoon (June through September)for beautiful falls; as falls dry down fast in Meghalaya. We could see water in only in 2 falls- Nohkalikai falls & Wah Kaba falls. If Meghalaya visit is planned during non-monsoon seasonsesp. November through' March, thenfalls are less awesome, but great for Arwah and /or Mawsmai limestone caves,living root bridge at Riwai &Dawki camp stay and boating in Umngot. Trust that this travelogue has been of value for your next trip to North East India - preciselyAssam, Arunachal Pradesh & Meghalaya visit.
Turtles Kaziranga Unicorn Rhinocerus
Way to Tawang 92 AOP GUJARAT AOP Gujarat WOMEN WINGS Initiative to form Women Wing for the Gujarat State IAP members was taken with the advice support and guidance of Dr Yogesh Parikh, President AOPG on 5th March 2021 During formation of WOMEN WINGS TEAM we took care all the members of the TEAM are a member of CIAP and AOP GUJARAT. We also kept regional balance - representative from all 5 zones of AOP GUJARAT. On 6th March 7 pm evening with support of Dr Yogesh Parikh and Dr Manish Mehta we organised our Launching inaugural ceremony of working committee team of Gujarat womens wing. Central and state IAP office bearers Dr Piyush Gupta, Dr G. V. Basavraj, Dr Santosh Soan, Dr Digant Shastri, Dr Sangita Lodha and Dr Swati Bhave, attended and send blessings and encouraging messages. Dr Shwetal Bhatt secretary introduced entire working team and guests. Our president Dr Nehal Patel addressed and shared her vision for the women and by the women's welfare activities to be planned and implemented. Dr Yogesh and Dr Manish promised their full support and gave encouraging suggestions. We urged everyone to celebrate International womens day in their work areas with full zeal. All zone members celebrated womens day in their capacity by organising awareness activities like Blood donation camp, Seminar talks, Skit and many more activities. Our working committee consisted of perfect blend of private practicing paediatricians and medical mentors, senior collegues and budding young paediatricians from all zones of Gujarat
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WOMEN WINGS TEAM 2021 Patron : Dr Pratima Shah - Ahemdabad, Dr Uma Nayak - Baroda, Dr Jashuben Takvani - Jamnagar, Dr Alka Rao - Bhuj Advisor : Dr Gargi Pathak - Ahemdbad, Dr Sheila Aiyer - Baroda, Dr Swatiben Popat - Rajkot, Dr Shushmaben Desai - Surat, Dr Sonal Shah - Jamnagar President : Dr Nehal Patel, Ahemdabad Secretary : Dr Shwetal Bhatt, Baroda Vice President : Dr Zankhana Sanghavi, Rajkot Treasurer : Dr Hiral Nayak, Ahmedabad Joint secretary : Dr Zalak Upadhyay, Rajkot EB Members : North Zone : Dr Sunita Agarwal, Dr Heena Desai Ahemdabad Zone : Dr Snehal Patel, Dr Dhara nanvati Central Zone : Dr Snehal Shirolawal, Dr Krutika Tandon Saurashtra Zone : Dr Urvi Sanghavi, Dr Namrata Parmar South Zone : Dr Ashwini Shah, Dr Nirali Mehta 94 AOP RAJKOT – Activities done in the year 2021 Since the start of year 2021, AOP Rajkot has been active in doing many programs - physical as well as virtual. Details are as follows :- Sr No Date Event Details 1 8/1/2021 BNCRP ToT Done - at COLORS GUJPEDICON 2020, at Sasan Gir (Pre Conference workshop) 2 8/1/2021 NTEP Done - at COLORS GUJPEDICON 2020, at Sasan Gir (Pre Conference workshop) 3 8th to 10th COLORS GUJPEDICON 2020- a destination First of it’s nature-HYBRID CONFERENCE January 2021 conference by AOP RAJKOT, at Sasan Gir (Both physical as well as virtual through dIAP platform) - with many national faculties and all 5 National CIAP President 4 1st week of Patient Education Program :- By Dr Neema Sitapara (Adolescent February 2021 Self awareness and stress management Pediatrician) - webinar done for adolescents of school in Rajkot 5 1st week of Research article – in Indian Pediatrics, Predictive value of IAP 2015, IAP 2007 February 2021 on Growth charts and WHO Growth charts in identifying pathological short stature - by Dr Chetan Dave (Pediatric Endocrinologist) 6 13th and 14th IMA Cricket tournament – Pedia Panthers Pedia Panthers reached upto semi finals in February 2021 the match, and also Man of the Match was from Pediatric team (AOP Rajkot supported the team financially too) 7 14/2/2021 Mega Blood donation camp By AOP Rajkot under Presidential action plan and PSSS, done at P D U Medical college, Rajkot 8 18/2/2021 Webinar by AOP Rajkot Topic:- Therapeutic , Prophylactic and functional use of probiotics : a current perspective. Speaker- Dr Jayesh Sonwani 9 21/2/2021 Patient education program For Type 1 DM kids, webinar done by Dr Zalak Upadhyay (Pediatric Endocrinologist) on insulin administration techniques 10 28th February TRUMMPS – training of upcoming medical Done by AOP Rajkot, trained 60 participants and 14th March and para medical staff (under Presidential 2021 action plan) 11 2/3/2021 Newer updates and management of BY AOP RAJKOT AND JEET (JOINT EFFORT tuberculosis FOR ELIMINATION OF TB) conducted a physical meet - had 4 speakers from Rajkot 95 AOP GUJARAT
Sr No Date Event Details 12 4/3/2021 World obesity day – patient education An article on increasing obesity in kids, with awareness importance of exercise and diet in newspaper-Phulchhab, by Dr Zalak Upadhyay (Pediatric Endocrinoloigst) 13 16/3/2021 Lady Pediatricians meet On Women’s day celebration – AOP Rajkot lady Pediatricians had a physical meeting Speakers – Dr Jhankhana Sanghvi and Dr Meera Dhami (on pneumococcal and meningococcal vaccine) 14 23/3/2021 Allergy testing in Pediatric Patients Webinar by Dr Major Nagaraju on the topic. This was conducted by AOP Rajkot, and included all Pediatricians from Saurashtra and Kutchh
BNCRP ToT- Group photo Dr Somashekhar Nimbalkar NTEP – as a pre conference workshop on as a faculty in BNCRP ToT 8/1/2021 - Inaugral program COLORS GUJPEDICON 2020 - Annual Gujarat State conference, done by AOP Rajkot at Sasan Gir (Destination conference) - first of its kind, Hybrid in nature
NTEP – as a pre conference workshop on All 5 CIAP Presidents After Installation ceremony of Present AOP 8/1/2021 - Dr Basavaraja G V taking a lecture Gujarat President Dr Yogesh Parikh
AOP Rajkot branch receiving the best branch award Dr Neema Sitapara taking a webinar for school at Gujarat level (1st in state) and at National level (2nd at National level) kids – Self awareness and Stress management 96 AOP GUJARAT
IMA premier league Mega Blood Donation camp Webinar on : Therapeutic, Prophylactic & AOP Rajkot reached upto Semi finals By AOP Rajkot under Presidential action plan functional use of probiotics : & PSS, done at P D U Medical college, Rajkot a current perspective
TRUMMPS- done by AOP Rajkot (trained 60 staffs) Patient education program - on insulin administration, site rotation for Type 1 DM kids, by Dr Zalak Upadhyay
Physical meet- by AOP RAJKOT AND JEET On Women's day celebration – AOP Rajkot (JOINT EFFORT FOR ELIMINATION OF TB) on lady Pediatricians had a physical meeting Newer Updates and management of Tuberculosis Speakers -Dr Jhankhana Sanghvi & Dr Meera Dhami ( on pneumococcal and meningococcal vaccine )
Webinar on Allergy testing in Pediatric Patients by Dr Major Nagaraju This was conducted by AOP Rajkot
An article on newspaper – by Dr Tushar Zalavadiya Publication by Dr Chetan Dave in On World Obesity Day – an article in newspaper on World Down syndrome day Indian Pediatrics on Growth charts on obesity awareness by Dr Zalak Upadhyay 97 AOP GUJARAT Academy of Pediatrics Vadodara Vadodara Adolescent Health Academy Year 2020-21 Date NAME OF ACTIVITY SPEAKERS/ ORGANISERS IN ASSOCIATION WITH 19.1.21 Nasal Blockage & Snoring In Dr Vikas Agrawal Sanofi India Ltd Children 20.1.21 Clinical Meeting January Dr Jalpa Dave; Dr Chitra Soni KGP Children Hospital 26.1.21 Republic Day Dr Ashutosh Singh Rathore Specialised Adoption Agency Vadodara 29.1.21 Allergic Testing in Pediatric Dr Prof Major K Nagaraju NA Office Practice 5.2.21 World Cancer Day Celebration Dr Urwinder Kaur, Dr Bhupendra KGP Children Hospital Kapadia, Dr Hitesh Vasava Munisewashram Goraj 5.2.21 World Epilepsy Day Dr. Sheila Iyer, Dr. Vaishali SSG Hospital Chanpura, Dr. Rinki Shah, Dr. Smruti Patel 10.2.21 Nutrition Education Program- Dr. Ketan Bharadva, Dr. Upendra CIAP, IAP Ahmedabad, IAP 11.2.21 Updated Kinjawadekar, Dr. Ke Elizabeth, Veraval, AOP Gujarat and Zuventus Dr. Neelam Mohan, Dr. Gv Basavrajadr. Hiren Patel, Dr. Samir Shah 13.2.21 Sexual & reproductive Health Dr Preeti Galgali VAHA, AOPVWW Awareness Day 7.2.21 World CHD Awareness Week Dr Prashant Modi, Dr Niranjan KGP Children Hospital, Parul 14.2.21 Shendrunikar, Dr Mahesh Bhatt, University, Sumandeep Vidyapeeth, Dr Chintan Bhatt, Dr Mukesh Isha Hospital, VCCC Hospital, Singh, Dr Tushar Shah Kilol Children Hospital 17.2.21 NRP Update 2020 Dr Prof Somshekhar Nimbalkar NNF 18.2.21 Clinical Meeting February Dr Naveen, Dr Lamsa Loki SSGH, Parul University 23.2.21 Pediatric Ophthalmology CME Dr Bharat Ramchandani 26.2.21 Learning From Friends Club Dr Hardik Dave, Dr Gaurav Patel, GSK Vaccine, Digishield Dr Tushar Shah 28.2.21 BNCRP Part 1 Dr Divya Dave, Dr Kedar Mehta, GMERS Gotri Dr Bhupendra Kapadia, Dr Hitesh Vasava, Dr Afsana Patel 2.3.21 Evidence Based Practice-Covid Dr Prasad Muley Parul University Vaccines 4.3.21 World Obesity Day Dr Roopal Panchani, Dr Hitesh VAHA, AACCI Desai, Mrs Meghna Shukla 8.3.21 International Women's Day Dr Swati Bhave AOPVWW, AACCI 14.3.21 World Kidney Day Dr Fagun Shah, Dr Jalpa Dave, KGPCH Dr Jagdish Patel, Dr Kinnari Vala, Dr Viral Shah 18.3.21 Clinical Meeting March Dr Anand Naregal, Dr Sarita Sharma SSGH, Neel Children Hospital 20.3.21 World Oral Health Day Dr Neelam Joshi, Harleen Soni MPDCH 21.3.21 World Down Syndrome Day Dr. Surekha Ramchandran, Dr. NA Smruti Patel, Dr. Roopal Panchani, 98 AOP GUJARAT
Date NAME OF ACTIVITY SPEAKERS/ ORGANISERS IN ASSOCIATION WITH Dr. Jitendra Jethani, Dr. Dhaval Parikh, Dr. Spoorthy Prabhu, Dr. Nidhi Saini, Dr. Satish Pandya 22.3.21 Rational Emotive Behaviour Therapy Dr. Satish Pandya, Dr. Swati Bhave VAHA, AACCI 23.3.21 Panel Discussion with Teenagers Dr. Swati Bhave, Dr. Satish Pandya, VAHA, AACCI Dr. Rk Baxi, Dr. Snehal Shirolawala, Dr. Kairavi Pancholi, Dr. Samir Shah 24.3.21 World Tuberculosis Day Dr. Umang Patel, Dr. Uma Kamat, Department of Pediatrics and Dr. Manjari Ninama Pulmonary medicine, SSG hospital; DTC Vadodara 25.3.21 World Teenage Day Dr. Samir Shah, Dr. Prashant Kariya, VAHA, AACCI Dr. Swati Bhave 26.3.21 Healthy Lifestyle Day Dr. Meenakshi Mehan, Foods and nutrition department Dr. Shruti Kantawal MSU, VAHA 27.3.21 Adolescent mental Health Awareness Students Of Msu Psychology VAHA, Department of Psychology MSU 28.3.21 Daughters Day Dr. Sushma Baxi, Dr. Shweta Shah, VAHA, IMA WW Dr. Nutan Shah
Glimpse of Activities
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102 AOP GUJARAT AOP Ahmedabad – Activities year 2021 Date Event Speaker 10th & 11th Derma Module Pramod Jog, Chetan Trivedi, Sameer Shah December 24th December Clinical Meet Baldev Prajapati, Riddhi Patel 27th December Bingo Night Parthiv Shah 3rd January Fire Symposium Bharat Gadhvi, Rajesh Bhatt 8th January Medicolegal Aspects In Clinical Practice Satish Tiwari, J K Gupta 19th & 20th Pneumonia Module Subramanian & Team January 28th January Clinical Meet Baldev Prajapati 30th January Pneumococcal Disease & Prevention Chetan Trivedi 31st January IPL- Day Format 10th & 11th NEP-U Module Elizabeth, Upendra, Ketan February 15th February Social Awareness Activity Deepa Trivedi, Abhay Shah, Geeta Khatwani, Vaibhav Shah 21st February Family Sports Fiesta 25th Feb Clinical Meet Baldev Prajapati, Kinnari Vala, Nidhi Dhamecha 28th Feb Ped Endo Update Anju Virmani, Vaman Khadilkar, Shalmi Mehta 4th March Obesity Awareness Program Nursing Staff, LG Hosp 13th & 14th Trumpps Prafful Patel, Manish Mehta, Sunil Patel March 21st March Pediatric Gastro Update Vishnu Biradar, Malthi Sakhiyasekaran, Aashay, Vaibhav 24th March 21st Century Teenager Nishchal Bhatt, Hirak Niak, Preeti Himani 25th March Clinical Case Discussion Baldev Prajapati
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104 AOP GUJARAT SPACT – Activities year 2021 Sr No Date NAME OF ACTIVITY SPEAKERS/ ORGANISERS 1 1/12/2021 Monthly Clinical Meet Brochure Atttached 2 1/24/2021 Infectious Disease CME Brochure Atttached 3 1/26/2021 Flag Hoisting SPACT - Dr Bipin Desai Chief Guest 4 1/29/2021 Webinar on Breastfeeding Dr Ashwini Shah 5 1/27/2021 Hepatittis A Vaccine Dr Vimal Jariwala 6 1/2/2021 Recharge, Rejuvanate and Emotional Dr Prashant Kariya , Mr Gautam Surana, First Aid Mrs Surbhi Surana 7 2/5/2021 Allergy testing in Pediatric Practice do we Dr Major Nagaraju need 8 2/8/2021 World Epilespy Day Brochure Atttached 9 2/14/2021 SPACT Family Box Cricket For Cause SPACT 10 2/15/2021 World Childhood Cancer Day Dr Nitin Shah 11 2/19/2021 Monthly Clinical Meet Brochure Atttached 12 2/27/2021 Dermatology Symposium Dr Unnati Parmar 13 2/16/2021 BLS Dr Prashant Kariya 14 2/25/2021 BLS Dr Prashant Kariya, Dr Santosh Yadav 15 3/3/2021 Chronic Urticaria in Children - Dr Sandipan Dhar An Approach to Management 16 3/4/2021 World Obesity Day Dr Piyush Gupta, Dr Rekha Harish, Dr Prashant Kariya 17 3/8/2021 International Women's Day Dr Priyali Bhattacharya 18 3/8/2021 International Women's Day Dr Afreen Jasani 19 3/11/2021 Pneumoccocal Vaccine Dr Nitin Shah 20 3/19/2021 Monthly Clinical Meet Brochure Atttached 21 3/20/2021 World Downs Syndrome Day Dr Surekha Ramchandran 22 3/21/2021 BNCRP Brochure Atttached 23 3/31/2021 Evidence Based Evaulation Of PCVs Dr Raju Shah
12th January - Clinical Meet 12th January - Clinical Meet 24th January - Infectious Disease CME Dr. Kirit Sisodiya Dr. Ashish Goti Inaugural Ceremony 105 AOP GUJARAT
Dr. Kirit Sisodiya reading the Citation of Panelist - Dr Sandip Trivedi, Dr Chetan Shah giving Dr Piyush Gupta for Dr Bipin Desai Oration Dr Digant Shastri and Dr Darshak Makadia Dr Bipin Desai Introduction
24th January - Installation Ceremony
27th January - Academic Talks 29th January - Breast feeding 05th February - Academic Talks Dr. Vimal Jariwala Dr. Ashwini Shah Dr. Major Nagaraju
08th February - World Epilepsy Day 15th February - MCQs on Childhood Cancer Dr Bakul Patel Dr Usma Patel Dr Ritesh Shah 106 AOP GUJARAT
16th & 21st February - Basic Life Support training 19th February - Clinical Meet Dr. Prashan Kariya Dr Kirit Sisodiya, Dr Ashish Goti, Dr. Umesh Bhimani, Dr Himanshi Tadvi
21th February - Box cricket
27th February - Dermatology Symposium 3rd March - Chronic urticaria in children : an approach to management Dr Unnati Parmar Dr Sandipan Dhar, Dr Jyant Upshyy, Dr Rakesh Desai 107 AOP GUJARAT
3rd March - World Obesity day 8th March - Women’s day 11th March - Pneumoccocal Dr Rekha Harish Dr Nitin Shah
19th March - Clinical Meet 20th March - World Downs Syndrome Day Dr Vipul Chechani, Dr Ashish Goti, Dr Viral Shah
21st March - Basic NRP Program
BNCRP Faculties Dr Kirit Sisodiya Dr Hitesh Patel
Dr Darshak Makadiya Dr Salim Hirani & Participants Dr Keyuri Shah
Dr Santosh Yadav Dr Upendra Chaudhri 31st March - Evidence based evaluation-PCVs Dr Abhay Shah 108 AOP GUJARAT
109 AOP GUJARAT BULLETIN Quiz Master : Dr Prashant Kariya, Dr Ankur Chaudhary, Dr Maulik Saliya First Five winner will get 1000 Rs. as a prize. QUIZ Powered by Dr. Chetan Shah, Anand Children Hospital, Surat. Send your answers on [email protected]
1. Which is the most common type of obesity ? A. Genetic Syndromes B. Endocrine Causes C. Leptin deficiency D. Exogenous Cause 2. Among the parameters of Metabolic syndrome like Waist Circumference >90th centile, BP >130/85, FBS >100, S. Triglyceride >150 and HDL cholesterol <40, what is the diagnostic criteria ? A. Waist Circumference >90th centile with any two of the others B. Waist Circumference >90th centile with any three of the others C. Waist Circumference >90th centile with any four of the others D. Waist Circumference >90th centile with all the others 3. Which of the following is a characteristic feature of Blounts disease? A. Genu Valgum B. Genu varum C. Coxa vara D. Coxa Valga 4. Which of following is false? A. HINE (Hammersmith Infant Neurological examination) scores of less than 40 in high risk infants between 3 to 6 months of age is predictive of non-ambulant CP B. HINE not useful to know severity and motor topography of CP. C. Combined diagnostic accuracy of General movements assessment and MRI is > 95% in < 5 months D. Combined diagnostic accuracy of HINE and neonatal MRI is > 90 % in > 5 months 5. Which of following has shown promising results in providing structured rehabilitation strategy for children with cerebral palsy? A. AI-based Robotics B. Brain computer Interface C. Virtual reality systems D. All 6. Signs of Proper latching are all except A. Baby's checks are filed and do not dimple. B. Nose is touching the breast and neck slightly flexed
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C. No fast sucking sounds. D. Jaw drops slowly and distinctly. 7. All of the following are true regarding baby's position while effective breast feeding in "Cross-Cradle Hold" with U support except. A. Baby's body should be gently pressed against the mothers body. B. Head, Neck and body should be in a straight line. C. Chin should be brought forward and close to the breast by extending the neck little out. D. Nose should be in the line with lower areola. 8. Physilogical genu valgum peaks at what age ? A. 2 Year B. 4 Year C. 5 Year D. 7 Year 9. False about Blounts disease is A. Developmental deformity of the proximal tibia involving Anterolateral physis B. Tibia Vara C. Limb Shortening D. Resulting in postcurvatum, varus and internal tibial torsion. 10.An error occured but the error did not reach the patient falls under which catagory of the impact of errors ? A. Category A B. Category B C. Category C D. Category D 11.An error occured that may have contributed to or resulted in permanent patient harm falls under which category of the impact of errors ? A. Category E B. Category F C. Category G D. Category H 12. Earliest sign of Neonatal Shock : A. Hypotension B. Increased Capillary filing time C. Tachycardia D. Tachycardia, increased Capillary filling time, temperature instability. 13. Role of Functional Echocardiography in neonatal Shock A. Identifying structural heart disease B. Type of fluid for resuscitation C. Type of inotropes to be used D. Type of fluid and inotropes to be used for resuscitation 14.Which of the following factor in bovine milk is involved in Accelerated Postnatal Growth ? A. GMPs ( glycomacropeptides) B. Insulinogenic amino acid C. Both D. None 15.Adeposity rebound , sensitive period for developing obesity occurs at which age? A. 4-5 yr B. 5-6 yr C. 6-7 yr D. 7-8 yr 111 AOP GUJARAT NEONATOLOGY Quiz Master : Dr Prashant Kariya, Dr Divya Rangoonwala First Five winner will get 1000 Rs. as a prize. QUIZ Powered by Dr. Chetan Shah, Anand Children Hospital, Surat. Send your answers on [email protected]
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Horizontal 3. Which intrauterine infection is responsible for congenital cataract, deafness and congenital heart disease? (7) 5. Hydrops fetalis in newborn can be caused by this viral infection (5) 7. Common site for Mongolian spot (11) 9. Test used to differentiate maternal from foetal blood (3) 11. Breastfeeding to be started in less than ---- hour after birth? (3) 12. Macrocephaly means large (4) 13. Cost effective method used to decrease hypothermia in preterm babies. It's commonly used short form (3) Vertical 1. Most common congenital anomaly in infant of diabetic mother (3) 2. Unilateral Moro reflex is seen in which palsy? (3) 4. Test used for antenatal diagnosis of Hyaline membrane disease in new born (7) 5. Index by which we can differentiate between symmetrical and asymmetrical IUGR (8) 6. Consumption by pregnant mother can be teratogenic (7) 8. Deficiency of this enzyme causes crigler najjar syndrome (4) 10. Parachute reflex disappears at which age? (5) 112 AOP GUJARAT
GUJPEDICON 17 18 19 DECEMBER First 1000 days care... Nurturing Lives, Creating Miracles
Organized by: Surat Pediatric Association Charitable Trust (SPACT)
Venue: Avadh Utopia, Surat
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Dr. Abhay Shah
Dr. Ashish Mehta Dr. Remeshkumar
Dr. Bakul Parekh Dr. Satish Pandya
Dr. Balasubramanian Dr. Tanu Singhal
Dr. Baldevbhai Prajapati Dr. Upendra Kinjawadekar
Dr. Digantbhai Shastri Dr. Raju Shah
Dr. Jagdish Chinnapa Dr. Raju Khoobchandani
Dr. Kasi SG Dr. Piyush Gupta
Dr. Major Nagaraju Dr. Nitin Shah
Dr. Nagabhushan Rao Dr. Neelam Mohan
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GUJPEDICON 17 18 19 DECEMBER First 1000 days care... Nurturing Lives, Creating Miracles
47th Annual Conference of Academy of Pediatrics, Gujarat Venue: Avadh Utopia, Surat I Organized by: Surat Pediatric Association Charitable Trust (SPACT)
Till 15th Till 30th Till 30th 1st Dec. June 2021 Sept. 2021 Nov. 2021 2021 onwards AOP and SPACT members 6000 6500 7000 8000 Non AOP; Non SPACT members 8000 8500 9000 10000 Accompanying delegate 6000 6500 7000 8000
PG students 6000 6000 6000 6000 Sr. Citizen AOP Member Nil Nil Nil Nil Corporate Delegate 8000 8500 9000 10000
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Patrons
Dr. Nirmal Choraria Dr. Digant Shastri
Dr. Vijay Shah Dr. Bankim Jariwala Dr. Kamlesh Parekh Dr. Rakesh Desai Org. Chairperson
Dr. Chetan Shah Dr. Kanak Surma Dr. Vimal Jariwala Dr. Hitesh Jariwala
Dr. Manish Sharma Dr. Prashant Kariya Dr. Fagun Shah Dr. Darshan Chauhan
Dr. Nirav Jariwala Dr. Kalpesh Dhangar
Dr. Kirit Sisodiya Dr. Ankit Parmar Dr. Pratin Shah (President) (Secretary) (Treasurer)
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Dr. Chetan Shah Dr. Digant Shastri Dr. Parang Mehta
Dr. Renu Gosai Dr. Mehul Pancholi Dr. Hitesh Jariwala Dr. Ketan Shah
Dr. Ravindra Chopra Dr. Darshan Chauhan Dr. Rajesh Prajapati
Dr. Salim Hirani Dr. Samir Shah Dr. Keyuri Shah Dr. Swati Vinchurkar
Dr. Praful Bambhroliya Dr. Ankit Parmar
Dr. Himanshu Tadvi Dr. Santosh Yadav Dr. Ketan Shah Dr. Ketan Bharadva Dr. Swati Vinchurkar
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Dr. Rajendra Verma Dr. Akshat Khemka Dr. Dinesh Bhutra Dr. Pradeep Sharan Dr. Kishor Kikani
Dr. Kamlesh Parekh Dr. Prashant Kariya Dr. Arun Trivedi Dr. Fagun Shah Dr. Ankit Parmar
Dr. Parang Mehta Dr. Sushma Desai Dr. Vishakha Mehta Dr. Ashwini Shah Dr. Nirali Mehta
Dr. Nirav Jariwala Dr. Bankim Jariwala Dr. Ankit Parmar Dr. Snehal Desai
Dr. Zainul Gagan Dr. Rohit Agrawal Dr. Pratin Shah Dr. Ricky master Dr. Zeemit Hirani
118 AOP GUJARAT Academy of Pediatrics Affix Gujarat Photo Membership Application Form
1. Name : (Surname) (First Name) (Second Name)
2. Present Status & Designation : 3. Office Address :
Mobile : E-mail :
4. Address (Resi.) :
Mobile : E-mail :
5. Registrations : (a) Number : (b) Authority :
6. Qualifications : University :
7. Year of Passing MD / DCH / DNB :
8. Central IAP Life Membership No. :
9. Category of Membership desired : (Lifetime / Ordinary / Associate / Associate Life / Student)
10. Name & Address of the Proposer :
Signature of the Proposer : 11. Name & Address of the Second Proposer (To be signed with stamp by local Branch President or Secretary :
Signature of the Proposer : Mailing Address of the Applicant : Signature of the Applicant : 12. Membership Fees : Annual Membership Rs. 1500/- • Life Membership Rs. 2000/- Proposer & Seconder must be members of AOP-Guj. Payment should be made by crossed demand draft or at par cheque drawn in favour of ‘Academy of Pediatrics, Gujarat’ OR in Cash OR Transfer to A/C. ‘Academy of Pediatrics, Gujarat’ ‘Union Bank of India, S. R. Marg Branch, A/C. No. 4449102010063062 (IFSC : UBIN0544914) 13. Cheque/NEFT receipt with duly filled form to be sent by Email or Post/Courier to "Secretary AOP Gujarat" Photo Copy May be used. Regd. Office : Ahmedabad Medical Association, Ashram Road, Ahmedabad. Dr. Manish Mehta, Hon. Secretary, AOP Gujarat Synergy Neonatal & Pediatric Centre 2nd Floor, Vishwam Complex, Dharnidhar Cross Road, Vasna, Ahmedabad-380007. E-mail : [email protected], [email protected] 119 AOP GUJARAT Blood Donation Camp in Covid Time 14th February, Sunday, Indian Academy of Prdiatrics, Rajkot
120 AOP GUJARAT Blood Donation Camp Media Coverage 14th February, Sunday, Indian Academy of Prdiatrics, Rajkot
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122 AOP GUJARAT Message from PSSSS Dr. Digant Shashtri Dear AOPG members, We hope that amidst the ongoing pandemic you and your family members are safe and doing well. Paediatrician social security scheme ( PSSS) is a noble attempt to help our AOPG members' family after unfortunate death. It is our moral duty to show brotherhood & help families of our members. As you know that in December 2019 Paediatrician social security scheme of AOPG came back in action after a gap of about 5 years. With this we take opportunity to update members about functioning of PSSS and current status. 1. In September 2020, DFC notice was sent to all members (which included DFC amount of 5 years & annual maintenance of 5 years with Rs. 200/- discount per year). More than 460 members have paid. 2. PSSS general body meeting held on 9th January 2021 had decided to allow late payment till 30th April,2021. Those who have yet not paid is sent final notice to pay by 15th May 2021 to avoid discontinuation of membership. 3. For ease of payment we have established Payment by UPI ID as well as online NEFT option also. 4. Accounts of all financial years till now are audited & IT returns have been filled. 5. Bank account at Surendranagar have been closed. All deposits & cash are under single account in Ahmedabad. 6. The change report at Charity commissioners office is submitted and is approved. 7. The membership database is updated and digital storage of application forms is started. 8. Since the inception total 507 members took membership of which 1 member had discontinued the membership and we have lost totally 10 members. Our future plans are:- (1) To invest a portion of total amount in the scheme to get better interest/ gain after consulting experts. Safety of the money is our topmost priority. (2) To make necessary changes in constitution. A committee has been constituted & all reforms will be after approval of GBM only. (3) Membership drive with a target to double the number to give maximum benifit to families of the diseased member. We humbly request to enroll yourself, your spouse for the PSSS. If you and your spouse both are already member in scheme motivate your friends. Thanking you, Yours sincerely. Managing Director & Chairman.... 123 AOP GUJARAT
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al Servic oci es ' S So ns ci a e i ty ic , r t A a O i P Pediatricians' Social Services Society d
G e P Form for NEW Member (P.S.S.S., AOP Gujarat) Society Reg. No. GUJ/3881/SUNR
FOR OFFICE USE ONLY DR. DIGANT D. SHASTRI Chairman & M. D. Appl. Revd. : Dt. Killol Children Hospital & M.A.D. Sign Neonatal Care Unit Passport Size 303, Takshashila Apartment, PSSS No. Latest Colour Majuragate, Surat-395 002 City Photograph Tele: (0261) 247 0130 Cell No. : 098795 38800 Birth Date 098795 68800 Email: [email protected] Group A B C D [email protected] Cert. Posted
SURNAME
FIRST NAME
MIDDLE NAME (Name of Father/Husband)
DATE OF BIRTH GROUP A B C D Male Female
QUALIFICATION
Membership No. : AOP CIAP
PAN Card
Aadhar Card
Correspondence Address
CITY PIN CODE
Phone No. : STD Code : (W) (R)
CELL : E-Mail
Suffering from any MAJOR disease ? YES NO : If YES * Please clarify here (Rule-1)
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PAYMENT Details: BANK Cheque No./ Transaction ID Amount Rs.
# Cheque should be drawn in favour of "Pediatricians' Social Services Society" (1) Pay by at Par Cheque / D.D. OR (2) Online Payment : (a) UPI ID : PSSS@unionbankofindia IFSC Code : UBIN0544914 (b) NEFT : A/c No. 449101010181041 Union Bank of India, Dr. S. R. Marg Branch, Ahmedabad I the undersigned apply of the membership of Pediatrician’s Social Services Society (PSSS). I do hereby declare that the above information is true and I have not with held any information whatsoever regarding the application. I agree to pay the amount demanded as per the details of the Scheme. I further agreed to abide by the condition laid down in the CONSTITUTION & RULES AND BYE LAWS of PSSS, I further agree to abide by the amendments, alterations, if any, in the future also. Date :
Place : Applicant's Signature & Stamp Proposed by PSSS No. of Proposer
Enclosures : (1) Copy of Birth Date Certificate (PAN Card/ School Leaving / Passport/ Driving Lic.) (2) Copy of Life Membership of AOP Gujarat (3) Payment evidence / cheque / online transfer copy. NOMINATION FORM
Nominee 1 Nominee 2
Name of the Nominees
Relation with Member
If Minor - Date of Birth & Guardian's Name and Relationship with Minor Specimen Signature of Nominee (If Minor, Sign. by Guardian)
Affix Photograph of Nominee Passport Size Passport Size Photograph Photograph of of Nominee 1 Nominee 2
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(1) If Suffering / suffered any MAJOR disease, than confirmation of membership is subject to approval by Panel (4 Drs' Panel of PSSS) & acceptance of window period by applicant.. (2) Eligibility criteria : Age < 60 Years, Life Membership of AOP Gujarat. (3) Death Fraternity Contribution (D.F.C.)
Age D F C (Per Death - Total Period for DFC Group (Years) to be paid) Payment (Years)
A < 35 1000 20 B 35 to 44 1200 18 C 45 to 54 1500 16 D 55 to 60 2000 14 Annul Maintenance Charge (AMC) to be paid every year for 20 years by each member
(4) Annual Maintenance Fee Rs. 1200/- / time to time decided by board. (5) Form to be filled up with Birth Date Evidence, Photo, Payment Evidence and Life Membership of AOP Gujarat Certificate. (6) Nominee will get Rs. 800/- x strength of PSSS (Total Number of Members on that date) Required Documents : (a) Death certificate (b) Original PSSS Membership Certificate (c) F I R, if Accidental Death. (d) Any other Documents, if needed & demanded by Board/Office. (7) Scheme will be managed by Managing Committee (Board of Directors) and Advisory Board for administration, fund management etc. (8) Once member is enrolled, he/she will get membership certificate, copy of rules and regulation.
Age Total Group Admission Membership Advance (Years) Fees Rs. Fees Rs. D.F.C. Rs. Payment Rs. A < 35 3000 1000 3000 7000 B 35 to 44 4000 1000 4000 9000 C 45 to 54 5000 1000 5000 11000 D 55 to 60 7000 1000 6000 14000
Members are advised to preserve photocopy of this duly filled up form for future reference.
December 2020 3 129 AOP GUJARAT
al Servic oci es ' S So ns ci a e i ty ic , r t A a O i P Pediatricians' Social Services Society d
G e P Form for SPOUSE Membership (P.S.S.S., AOP Gujarat) Society Reg. No. GUJ/3881/SUNR
FOR OFFICE USE ONLY DR. DIGANT D. SHASTRI Chairman & M. D. Appl. Rcvd. : Dt. Killol Children Hospital & M.A.D. Sign Neonatal Care Unit Passport Size 303, Takshashila Apartment, PSSS No. Latest Colour Majuragate, Surat-395 002 City Photograph Tele: (0261) 247 0130 Cell No. : 098795 38800 Birth Date 098795 68800 Email: [email protected] Group A+ B C D [email protected] Cert. Posted
SURNAME
FIRST NAME
MIDDLE NAME (Name of Father/Husband)
DATE OF BIRTH GROUP A+ B C D Male Female
QUALIFICATION PAN Card Aadhar Card Correspondence Address
CITY PIN CODE
Phone No. : STD Code : (C) (R)
CELL : E-Mail
Suffering from any MAJOR disease ? YES NO : If YES * Please clarify here (Rule-1)
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PAYMENT Details : BANK Cheque No./ Transaction ID Amount Rs.
# Cheque should be drawn in favour of "Pediatricians' Social Services Society" (1) Pay by at Par Cheque / D.D. OR (2) Online Payment : (a) UPI ID : PSSS@unionbankofindia IFSC Code : UBIN0544914 (b) NEFT : A/c No. 449101010181041 Union Bank of India, Dr. S. R. Marg Branch, Ahmedabad I the undersigned apply of the membership of Pediatrician’s Social Services Society (PSSS). I do hereby declare that the above information is true and I have not with held any information whatsoever regarding the application. I agree to pay the amount demanded as per the details of the Scheme. I further agreed to abide by the condition laid down in the CONSTITUTION & RULES AND BYE LAWS of PSSS, I further agree to abide by the amendments, alterations, if any, in the future also.
Date :
Place : Applicant's Signature & Stamp
Enclosures : (1) Copy of Birth Date Certificate (PAN Card/ School Leaving / Passport/ Driving Lic.) (2) Marriage Evidence Documents (3) Payment evidence cheque / online transfer copy.
NOMINATION FORM
Nominee 1 Nominee 2
Name of the Nominees
Relation with Member
If Minor - Date of Birth & Guardian's Name and Relationship with Minor Specimen Signature of Nominee (If Minor, Sign. by Guardian)
Affix Photograph of Nominee Passport Size Passport Size Photograph Photograph of of Nominee 1 Nominee 2
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PSSS No. of Main Member
Name of PSSS Member City
Name of Spouse
Father's Name of Spouse
1st Contact Pediatrician's Name
Address :
Pin Contact E-mail
2nd Contact Pediatrician's Name
Address :
Pin Contact E-mail
* One of the above two contacts must be PSSS Member. We both have read all rules & regulations & It's our joint responsibility for every matter.
Signature of PSSS Member Signature of Spouse
Attachment : ONE OF FOLLOWING (1) Marriage Evidence (Pan Card, Passport Copy, Marriage Registration Certificate) (2) Marriage Affidavit Copy (3) Notary Attested Copy (4) Any Certificate Showing Marital Status. 3 132 AOP GUJARAT RULES & REGULATIONS
(1) If Suffering / suffered any MAJOR disease, than confirmation of membership is subject to approval by Panel (4 Drs' Panel of PSSS) & acceptance of window period by applicant.. (2) Eligibility criteria : Age < 60 Years (3) Death Fraternity Contribution (D.F.C.)
Age D F C (Per Death - Total Period for DFC Group (Years) to be paid) Payment (Years)
A + < 35 1200 20 B 35 to 44 1200 18 C 45 to 54 1500 16 D 55 to 60 2000 14 Annul Maintenance Charge (AMC) to be paid every year for 20 years.
(4) Annual Maintenance Fee Rs. 1200/- / time to time decided by board. (5) Form to be filled up with Birth Date Evidence, Photo, and Payment Evidence (6) Nominee will get Rs. 800/- x strength of PSSS (Total Number of Members on that date) Required Documents : (a) Death certificate (b) Original PSSS Membership Certificate (c) F I R, if Accidental Death. (d) Any other Documents, if needed & demanded by Board/Office. (7) Scheme will be managed by Managing Committee (Board of Directors) and Advisory Board for administration, fund management etc. (8) Once member is enrolled, he/she will get membership certificate, copy of rules and regulation.
Total Associate Age Admission Membership Advance Payment Rs. Group Membership (Years) Fees Rs. Fees Rs. D.F.C. Rs. from fee 16-06-2015* A < 35 3000 1000 3000 1000 8000 B 35 to 44 4000 1000 4000 1000 10000 C 45 to 54 5000 1000 5000 1000 12000 D 55 to 60 7000 1000 6000 1000 15000
Members are advised to preserve photocopy of this duly filled up form for future reference.
December 2020 4 133 AOP GUJARAT
We are proud to be a real warriors
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