Editorial

ABSTRACT

Objective: To determine the minimum effective maintenance dose of vitamin D supplements given as pulse therapy in children
Study Design: A Randomized Prospective Study
Place and Duration of Study: Pediatrics Department, Liaquat University Hospital, Hyderabad and Bachal Soomro Primary School, Hyderabad from March 2018 to February 2019
Material and Methods: Children between 6 months to 12 years having subclinical vitamin D deficiency were included in the study. A total of 110 Children who fulfilled the inclusion criteria i.e. result of a vitamin D level below ≤30 nmol/litre were enrolled for the study. There were 2 groups, group A (LUMHS OPD) children received 100, 000 units of Vitamin D3 orally and group B children (Bachal Soomro Primary School) received 3 lac units orally. There were 37 children in group A, while 73 children in Group B. Serum vitamin D level was checked after 6 months of vitamin D supplement.
Results: Results showed, that in samples of 3-lac unit dose the mean vitamin D3 level was 15.7 (SD = ±6.0) was raised significantly after six months of treatment with a mean value of 20.9 (SD ±4.9), p<0.01 obtained using paired sample t-test. More, in samples of 1-lac unit dose, the mean vitamin D3 level was 23.4 (SD = ±15.5) did not give any significant effect of treatment , and after six month the mean value of vitamin D3 was 20.2 (SD ±12.1). A Decrease in mean is considered statistically insignificant with a p-value of 0.268.
Conclusion: A bolus dose of Vitamin D3 three lac units can be given every six months as a maintenance dose, while one lac unit is not effective when given every six months.
Key Words: Vitamin D deficiency, Maintenance dose, Bolus dose, Oral dose, Children

ABSTRACT

Objective: To determine the frequency of vitamin B12 deficiency among admitted pediatric patients having macrocytic anemia and the reasons for their admissions.
Study Design: Descriptive, cross sectional.
Place and Duration of study: Pediatric department of Dr. Ruth K. M. Pfau Civil Hospital Karachi, from April 2017 to March 2019.
Material and Methods: Medical records of patients 1 month to 12 years of age having an MCV higher than 85 fL and hemoglobin below 10.5 g/dl were inducted into the study by non-probability convenient sampling. Cause of macrocytosis was evaluated using history, examination and investigations including levels of serum B12 and Folate. Low serum B12 was defined as a value below 148 pmol/L. Data was analyzed using SPSS version 22.
Results: The total study population consisted of 90 children, out of which majority (95.5%) were found deficient in vitamin B12. 77.7% had concomitant deficiency of folic acid. 52.3% patients with B12 deficiency were male. Mean age was 3.5 years. 54.65% cases had either severe or very severe B12 deficiency. 62.2% of the cases having macrocytosis were related to malnutrition. Most of the remaining 37.7% cases had diseases not associated with macrocytosis as per literature. Most common among them was malaria diagnosed in 11% patients. Concomitant deficiency of vitamin B12 was observed in conditions known as non-megaloblastic causes of macrocytosis like leukemia, Down’s syndrome and hemolytic anemia.
Conclusion: Vitamin B12 deficiency was documented in patients irrespective of gender, age or the diagnosis for which the patients were admitted. It was also seen concomitantly in conditions known to have non-megaloblastic macrocytosis.
Key Words: Anemia, Macrocytic anemia, Megaloblastic anemia, Vitamin B12, Vitamin B12 deficiency

ABSTRACT

Objective: To compare mean decrease in stool frequency in patients with zinc supplementation versus placebo in addition to ORS in children with acute diarrhea.
Study Design: Randomized control study
Place and Duration of Study: The study was held at diarrhea ward of the Institute of Child Health and Children’s Hospital Lahore from 15 March to 15 September, 2017.
Material and Methods: Inclusion criteria was children age 6 months to 5 years with duration of diarrhea <3 days An informed consent was taken. Group A was considered as zinc supplemented group and given syrup zinc sulfate 20 mg/day plus ORS while group B as placebo group and was given ORS and placebo dextrose saline solution 20 ml daily. Final outcome was measured on day 7 by determining the decrease in stool frequency in zinc group as compared to placebo.
Results: Amongst 150 cases, in Zinc and Placebo group mean duration of diarrhea was 7.75 ± 4.19 days and 8.87 ± 3.78 days respectively with same mean duration, p-value >0.05. After treatment (7th day), mean decrease in frequency of stool was significantly high in Zinc group (8.20 ± 4.13) when compared to placebo group (3.15 ± 4.47), p-value <0.001.
Conclusion: Amongst children, supplementation of zinc with addition of ORS results in reduction of frequency of stools so zinc can significantly reduce the diarrhea and its complications.
Key Words: Zinc, Diarrhea, ORS.

ABSTRACT

Objective: QT interval is an independent risk factor towards sudden deaths. QT interval mathematical correction formulae lead to under or over diagnosis as these were not designed for high heart rates found in children. This study was aimed at developing nomograms for calculating physiologically normal range of QT interval in children.
Study Design: It was community based cross sectional observational study.
Place and Duration of Study: The study was conducted at The Children’s Hospital, Lahore, Pakistan from July 2020 to Feb 2021.
Material and Methods: A 12-lead screening electrocardiogram was recorded on children invited from local urban community. ECGs manually assessed for conduction time. Mean with 2SD assessed. Regression tests applied and outliers removed. Quantile charts plotted with multiple trendlines.
Results: A total of 1256 children had screening ECG done with M:F;1.2:1 and mean age was 47.3 + 35.1 months. Mean heart rate was 110 + 24 beats per min. Mean QT interval was 317 + 41 msec. Centiles were curtailed to 5, 10, 25, 50, 75, 90 and 95th centile for relevant nomograms. Cubic regression fitted the model best. Males showed wider area of dispersion and slightly higher centile values in young children.
Conclusion: Assessing QT interval using 5th and 95th centiles on nomogram can better identify prolonged or short QT interval efficiently. Hence, over and under diagnosis of prolonged or short QT interval can be avoided, preventing unnecessary anxiety and burden of tests for further evaluation on one hand, and readily identifying outliers with actual risk on the other hand among children.
Key Words: Child, Electrocardiogram, Infant, Heart conduction system, Long QT interval.

ABSTRACT

Objective: The aim of study is to look for clinical spectrum and echocardiographic features of particularly valvular involvement in children with rheumatic heart disease.
Study Design: Observational study.
Place and Duration of Study: For this observational study, 451 subjects were recruited over 3.5 years from 1st January 2018 till 30th June 2021 presenting for the first time in Children Hospital/DHQ hospital Faisalabad.
Material and methods: Demographical profile, clinical spectrum and pattern, and severity of valvular involvement were recorded in pediatric population and analyzed by SPSS version 20.0
Results: Among the 451 enrolled children, male to female ratio was 1:1.3 with age range between 60 to 194 months (median 125 months). 71.4% patients belonged to rural areas. In this cohort, 143 (31.7%) were hospitalized due to congestive heart failure, 102 (22.8%) with recurrence of acute rheumatic fever, 78 (17.3%) with LRTI and 6.3% with arrhythmia. 83.4% had mitral valve involvement. Mitral regurgitation was present in 51.9%, isolated mitral stenosis (MS) was in 2.0% and mixed mitral valve disease (Combination of MR and MS) was in 5.9%. Aortic regurgitation (AR) in isolation was present in 3.8%.
Conclusion: In conclusion, mitral valve is the most commonly involved valve in RHD in our study and mitral regurgitation followed by multi-valvular (dual-valve) involvement are the most common lesions. Majority of the cases had already progressed to severe valvular lesion at their first presentation to an equipped hospital. Congestive heart failure is the most common presentation followed by recurrence of acute rheumatic fever.
Key Words: Rheumatic heart disease, Valvular lesion, Children

ABSTRACT

Objective: To find out clinical presentations and GBS variants among patients in a Tertiary care Hospital of Hazara division.
Study design: A cross-sectional study.
Place and Duration: It was conducted in all units of Neurology, Medicine and Pediatrics Departments of Ayub Teaching Hospital, Abbottabad over duration of four years from 12.11.2017 till 14.01.2021.
Materials and Methods: By consecutive sampling techniques, patients diagnosed clinically with GBS according to diagnostic criteria and confirmed by electrodiagnostic studies were selected. Data and results of electrodiagnostic studies were recorded on a specified proforma. Due to patient refusal, a lumbar puncture couldn’t be performed in most, hence was not included in the final analysis. Using SPSS version 16, descriptive test and chi-square test were applied for data analysis. P-value <0.05 was considered significant.
Results: From total of 51, 35(68.6%) were males, overall mean age was 37.8±18.891 years (min 10 and max 75 years). Among clinical presentation of GBS, motor weakness 33 (65.7%) and quadriplegia 29 (56.9%) appeared the most common. Electrodiagnostic studies recorded acute motor axonal neuropathy (AMAN) as more prevalent observed in 18 (35.3%) patients.
Conclusion: The clinical presentation and GBS variants of the Hazara population of Pakistan slightly differed from the available literature. Younger age groups were affected more, however, the predominance in males remains similar to current literature. Motor weakness and quadriplegia were most common presentations and AMAN was the most common variant.
Key Words: Guillain-Barré syndrome (GBS); Variants; Motor weakness; Acute motor axonal neuropathy; Acute flaccid paralysis; Acute post infectious polyneuropathy, electrodiagnostic tests

ABSTRACT

Objective: To evaluate the effect of wakeful prone position as determinant of motor development in cerebral palsy
Study Design: A quasi-experimental study was conducted.
Place and Duration of Study: A sample of 180 children with spastic quadriplegic cerebral palsy was taken from two rehabilitation setups from December 2018 to October 2019 in infants with spastic quadriplegic cerebral palsy.
Material and Methods: The participants aged between 1-3 years with GMFCS level V and Modified Ashworth Scale 2 as baseline were recruited in the study. Wakeful prone position along with colorful, musical, visual and auditory toys was introduced to focus tracking and reaching and also to improve their intrinsic drive. The sessions were divided for 2-3 hours a day in different time intervals at clinical and home settings. Intervention time was 2 to 3 hours for six days a week for six months. Data was collected and assessed through Gross Motor Function Measure-88.
Results: The results of the study showed significant improvement in test scores in all dimensions lying, rolling, sitting position, crawl, kneeling, standing, walking and running. Paired t-test showed significant improvement after intervention (p<0.05).
Conclusion: The study revealed that wakeful prone positioning is effective in improving gross motor function in children with spastic quadriplegic cerebral palsy.
Key Words: Cerebral Palsy, Postural reflex, Prone position, Quadriplegia, Spasticity.

ABSTRACT

Objective: To study the incidence and comparison of various SRCTs in relation to age, sex and site distribution.
Study Design: Cross-sectional
Place and Duration of Study: The present study was undertaken in histopathology laboratory at Besat Hospital in Hamadan, Iran for period of 12 years from April 2009 to March 2021.
Material and Methods: All specimens admitted with pathology findings as SRCT were included. Tissues were processed and histopathological and immunohistochemical studies were done and recorded.
Results: Out of 176 cases 72 (41%) were female and 104 (59%) were male with the mean age of 33.72 ± 26.96 years. Small cell carcinoma was the most common type of SRCTs (23.9%) followed by Ewing Sarcoma (ES)/Primitive Neuroectodermal Tumor (PNET) (17.6%), non-Hodgkin's lymphomas (14.7%), Wilms tumor (10.2%) and Neuroblastoma (8.5%). IHC staining was performed for 87 cases (49.4%).
Conclusion: The demographic characteristics of SRCTs vary as much as their diversity. Obviously, it is necessary for the pathologist to confirm the final diagnosis by checking the consistency of the diagnosis with the patient's initial clinical information according to the statistics recorded in valid reference books and articles.
Key words: Small round cell tumor, Pathology, Ewing sarcoma, PNET, Small cell carcinoma

ABSTRACT

Objective: To determine the clinical presentation, associate complication and surgical outcome of myelomeningocele repair.
Study design: Descriptive study.
Place and Duration of Study: The study was conducted at Neurospinal and Cancer care Institute, duration between 12 -03-2012 to 16-03-2019.
Material and Methods: Inclusion criterion was patient between age birth to 12 months having meningomyelocele with hydrocephalus or other neural tube defect. Exclusion criterion was previously operated, infected myelomeningocele (MMC). Factors such social status, folic acid intake during pregnancy, and associated anomalies were recorded on a structured proforma.
Results: A total 114 children were included; socio-economic status was low in 71% and poor intake of folic acid was present in 83%
{p value (p<0.05)}. Based on position of defects, 64% was at the lumbosacral area, 20.14% were at lumbar spine area and 7.89% were thoracic. The Cerebrospinal fluid leak was observed in 3.5%, superficial wound infection in 0.87% and no mortality was observed post procedure.
Conclusion: Low socio-economic status and poor folic acid intake before and during pregnancy are significantly associated with MMC. Early surgical repair is associated with less post procedure complication.
Key Words: Meningomyelocele, Surgical repair, Hydrocephalus, Prenatal repair

ABSTRACT

Objective: The main aim was to assess the difference in attitudes towards COVID 19 vaccine acceptance among vaccinated and unvaccinated medical students. Secondary aim is to determine the factors affecting vaccine acceptance among medical students
Study Design: Descriptive cross-sectional study
Place and Duration of Study: Study was conducted online. Duration:6 weeks
Material and Methods: The study was conducted online with help of a predesigned online questionnaire. Undergraduate and postgraduate medical students of different medical universities in Karachi were included in the study. Statistical analysis was carried using SPSS version 22.
Results: Out of 419 participants, 309 (73.7%) were female and 110 (26.3%) were males. Mean age was 22.54 ± 2.i4 years. 74 (17.7%) participants were vaccinated for COVID-19 and 345 (82.3%) were unvaccinated. Among the unvaccinated, 212 (61.4%) were willing for vaccination whereas 82 were (23.7%) not sure and 52 (12.4%) said no. Results were compared in two groups: Group A- vaccinated for COVID-19 (n=74) and Group B unvaccinated for COVID-19 (n=345). Group A had fewer concerns about vaccine side effects, more faith in data providers and more willingness to get vaccinated.
Conclusion: Vaccinated medical students are more likely to convince colleagues and others to get vaccinated which shows positive attitudes and hopes for the future.
Key Words: COVID-19, Medical students, Vaccine hesitancy

ABSTRACT

Objective: To evaluate the effects of body weight supported treadmill training on balance and gross motor function in patients with cerebral palsy and developmental delay.
Study Design: Quasi experimental pre and post study with convenient based sampling technique.
Place and Duration of Study: Pediatrics Rehabilitation Unit, Department of Physiotherapy, Liaquat National Hospital, Karachi. from 1st January 2019 to 31st December 2019.(remove this duration please)
Material and Methods: Total 50 participants fulfilled eligibility using inclusion criteria of age 5-15 years, Gross motor function classification score (GMFCS) level more than II, known case of Developmental Delay and Cerebral Palsy. Body Weight Support Treadmill was performed for total 14 days. Baseline assesment was done through Gross motor function classificaton score. Gross Motor functioning measurement (GMFM-66) and Pediatric Balance Scale (PBS) were used as pre and post-test assessment tool for measuring gross motor and balance respectively.
Results: The mean age of participants was 4.90 ± 1.129 with 32 (64%) males and 18 (36%) female population. Paired t-test was used to find pre and post effects of body weight supported treadmill on Pediatric Balance Scale (PBS) and Gross Motor Function Measurement (GMFM)-66 and the results were significant with 0.001 and 0.002 P-values respectively. Frequency of GMFM-66 and PBS were also compared. PBS results showed that balance was improved in 20% participants whereas GMFM-66 results showed that gross motor functioning was improved in 63% of participants.
Conclusion: Body weight supported treadmill helped in improving gross motor as well as balance.
Key Words: Balance, Cerebral palsy, Developmental delay, Gross motor function, Treadmill

ABSTRACT

Objective: To show the frequency of vertebral defects associated with gastrointestinal anomalies.
Study Design: Descriptive Case study.
Place and Duration of Study: The study was conducted at the Radiology department of Children Hospital in collaboration with Paediatric Surgery, Pakistan Institute of Medical Sciences, Islamabad from October 2017 to August 2018.
Material and Methods: One hundred and eighty one patients (109 males and 72 females) were included in the study to find the frequency of associated vertebral defects in patients of upper and lower gastrointestinal anomalies. Upper gastrointestinal anomalies were confirmed through Barium swallow while children with lower GI anomalies underwent Distal Loopogram. X-ray Spine was done to rule out congenital spinal deformity.
Results: Out of 181 cases, 64 (35%) cases were identified with vertebral defects among all GI anomaly cases. Among the vertebral defects, coronal cleft vertebrae was found to be the most common (66.7%) deformity followed by Hemi-vertebrae (16%) while L5 and S1 vertebrae were observed to be most common site (n=18, 45%) of spina bifida in patients of lower GI anomalies.
Conclusion: Patients having vertebral defects associated with gastrointestinal anomalies should undergo a thorough physical and radiological examination to avoid misdiagnosis and incurable complications.
Key Words: Gastrointestinal anomalies; Vertebral defects; Barium swallow; Spina bifida

ABSTRACT

Objective: To assess the effect of conjugate reinforcement of leg movements in infants with Spina Bifida.
Study Design: Cross-sectional study
Place and Duration of Study: University Teaching Hospital, University of Lahore from May 2019-Dec 2019.
Material and Methods: The voluntary leg movements of 10 infants with Spina Bifida were videotaped in supine: baseline (untethered), acquisition (tethered to a mobile), & extinction (untethered) with rest interval between each. The babies were active while taking the data.
Results: Infants produced more leg movements when tethered to a mobile than baseline (p= 0.042) & also performed more total kicks when tethered to a mobile than baseline (p=0.016). Single kicks were the most common type.
Conclusion: Most of the babies with Spina Bifida generated more movements and kicks when tethered to a mobile. In addition to number of leg movements and kicks, each infant gave a discrete reaction to mobile paradigm with complex and new kind of kicks in different conditions as compared to baseline. Clinically, the leg muscles strengthening, and neuromuscular association of Spina Bifida infants can be increased with mobile paradigm that led to more kicks.
Key Words: Spina bifida, Infants, Lower extremity

ABSTRACT

Objective: This paper aimed to model the proxies of obesity by using waist circumference (WC), age, and gender of the school-going children aged 10-16 years. Develop a model of body fat percentage using body mass index. Also, identify the risk factors that effects obesity in children.
Study Design: This was a cross-sectional study.
Place and Duration of study: This study was conducted in District Multan. The duration of the study was four months, from February to May 2019.
Material and Methods: In this cross-sectional study a sample of 370 school-going children aged 10-16 years was collected. The anthropometric indicators were analyzed using descriptive statistics. Multiple regression and logistic regression models were used for modeling obesity.
Results: The males 46% and females are 54%. The mean ± S.D of body mass index (BMI), body fat percentage (BFP), and body adiposity index (BAI) are 20.52±3.37, 20.76±5.787, and 50.83±11.06 respectively. The mean height, BMI, and BFP of the male are statistically significant (p<0.01) as compared to female children.
Conclusion: The waist circumference is significant (p<0.05) for modeling BMI, BFP, and BAI. BMI is significant (p<0.01) in the prediction of BFP.BMI and BFP have similar results as these are highly associated measures. BMI and age will predict BFP more accurately with high precision. The risk of obesity can be reduced by controlling WC in children. The developed models will be used in further clinical studies for measuring and modeling obesity in children.
Key Words: Body mass index, Body fat percentage, Body adiposity index, Waist circumference, Obesity, Regression modeling.

ABSTRACT

Objective: Acute respiratory illness (ARI) is one of the top diagnoses for paediatric hospital admissions in Pakistan which is aggravated by the escalating problem of air pollution, especially over Punjab. The objective of this study was to discover the relationship of Air Quality Index (AQI) with proportion and severity of ARI in pediatric population.
Study Design: Retrospective study
Place and Duration of Study: This Study was conducted at the Punjab Rangers Teaching Hospital, Lahore over 2 years during winter smog seasons Oct 2018 - Feb 2019 and Oct 2019 - Feb 2020.
Material and Methods: Data was collected from medical records on pediatric inpatients with ARI. AQI levels were obtained from Air Quality reports and analysed with patient information using SPSS V.21.
Results: In winter smog season 2018-19, 1/5th of pediatric admissions were due to ARI, with average AQI level of 147. This fell by 50%, in the following winter, with an AQI level decline by 16%. 95% of patients with ARI were under 5 years of age and 60% were male. 65% had moderate to severe respiratory distress and 80% required oxygen supplementation. The severity of respiratory distress was observed to be worse with higher AQI levels (p=0.024), with higher frequency in bronchopneumonia (p=0.045). The proportion of cases with severe respiratory distress was 17.6% (95% CI 8.0- 31.0) over 5 months with mean AQI 138.96.
Conclusion: There is a significant association with air pollution and severity of ARI in children <5 years of age.
Key Words: Air quality index, Acute respiratory illness, Pollution, Severity

ABSTRACT

Empyema Necessitans refers to the spread of pus from the pleural cavity into adjacent soft tissue structures; and usually presents as a bulge over the thoracic wall or a pleuro-cutaneous fistula. There are medical and surgical options for management of these patients. The choice of antibiotics in empyema necessitans is determined by the etiological organism; and Methicillin Resistant Staphylococcus Aureus (MRSA) is one of the reported causes. We report two cases with unusual presentations of MRSA-associated empyema necessitans. Patient 1 was a 2-month old child who presented with fever, respiratory distress and a painful bulge on left side of chest. Radiological investigations revealed left pleural effusion with extent into chest wall subcutaneous planes. There was associated 4th rib osteomyelitis. Pus culture showed MRSA growth and the patient was managed with intravenous antibiotics along with chest-tube thoracotomy and drainage of abscess. Patient responded and was subsequently discharged. Patient 2 was a 10-year old boy who presented with right knee swelling after trauma 7 days back. This was followed by swelling over left side of chest extending to left side of neck and back. Work-up revealed loculated left-sided empyema necessitans with MRSA as the cause. Patient underwent incision and drainage of knee and back abscesses along with chest tube thoracotomy and intravenous antibiotics. The authors propose that further studies be done on these patients to formulate management guidelines.
Key Words: Empyema necessitans, Methicillin-resistant Staphylococcus Aureus, Pleural effusion

ABSTRACT

Staphylococcal aureus infection in children is a major public health problem globally. It causes a varied spectrum of clinical disease including bacteremia, endocarditis, skin and soft tissue infection, pleuro-pulmaonry and osteo-articular infection. Deep vein thrombosis (DVT) is a known complication of staphylococcal infection. We report a case series which included, 10-year old boy developed DVT, septic pulmonary emboli and Methicillin-resistant Staphylococcal aureus (MRSA) bacteremia following a furuculosis and 13 year old girl with thrombosis of internal and external jugular vein, cavernous sinus with pulmonary emboli and MRA bacteremia. Both patients are previously healthy showed complete recovery after aggressive appropriate antibiotics, anticoagulants and supportive care. The high index of suspicion of DVT in MRSA infection is needed, prompt diagnosis and aggressive appropriate therapies improve the outcomes and minimize the complications.
Key Words: Deep vein thrombosis, Methicillin-resistant staphylococcal aureus bacteremia and septic pulmonary emboli

ABSTRACT

Suicide is a public health problem. Suicide by hanging is seen in all ages, starting around the age of 10-12. "Hanging injuries" is the term used to refer to people who survive after hanging. We present the case of a pediatric patient who survived mechanical asphyxia by hanging.
A 12-year-old female patient who recently attempted suicide by hanging herself was admitted to the nearest hospital presenting "near-hanging injuries." She received ventilatory support and sedation-analgesia in the Pediatric Intensive Care Unit (PICU), treating cerebral edema with mannitol. Upon discharge, she presented neurological and structural sequelae.
Although suicide is one of the most common causes of death in the pediatric population, near-hanging injuries are rare in this setting. Patients with these injuries should be treated aggressively and early to avoid possible complications. In this case, the family's action and the late treatment influenced the lousy evolution of the patient.
Key Words: Child, Neck injuries, Attempted suicide, Asphyxia, Resuscitation

ABSTRACT

This study was conducted at Fazle Omar Hospital Rabwah from December 2017 to December 2018 and comprised patients admitted with neonatal sepsis. Vitamin D deficiency was present in 70% of patients. There was no significant difference between mortality rates of the neonates having vitamin D deficiency, normal Vitamin D levels and those with hypervitaminosis D.(p=0.22)
Keywords: Vitamin D, Neonatal Sepsis, Mortality.