Infection Prevention and Control Measures at the Children Hospital Lahore: A My Child Matters Collaborative Project.

PURPOSE: Infection prevention among children with cancer is a major challenge at Children Hospital Lahore (CHL), a public health care facility in Pakistan with 1,000 new pediatric cancer admissions annually. The objective has been to reduce infections through collaboration between CHL and the St Jude Children's Hospital Global Infectious Disease program via a grant by the Sanofi Espoir foundation through the My Child Matters program. The aim of the current study was to describe the effect of the collaborative improvement strategy on existing infection prevention and control (IPC) standards at CHL. MATERIALS AND METHODS: Our work was a prospective before-and-after study to improve IPC standards. We compared the WHO Hand Hygiene Self-Assessment Framework and four modules of the St Jude modified Infection Control Assessment Tool (ICAT) scores over a 3-year period. Our strategy included creating a multidisciplinary team of pediatric oncologists, infectious disease physicians, nurses, a microbiologist, and a data manager; engaging in monthly online IPC mentoring sessions with St Jude Children's Hospital Global Infectious Disease program and My Child Matters mentors; performing daily inpatient health care-associated infection surveillance rounds; and performing regular hand hygiene training and compliance audits. RESULTS: Baseline needs assessment showed health care-associated infections identified by positive blood cultures as 8.7 infections per 1,000 patient-days. Deficient hand hygiene supplies, health education measures, and bed sharing of neutropenic patients were identified as major challenges. Our hand hygiene facility level, per WHO scores, increased from Inadequate to Intermediate/Consolidation by the end of the 3-year implementation (122 v 352 WHO Hand Hygiene Self-Assessment Framework scores). The sink:bed and hand sanitizer:bed ratios improved to 1:6 and 1:1, respectively. The ICAT general infection control module increased by 40% (45 v 78 ICAT scores) and hygiene compliance improved by 20%. CONCLUSION: Implementing a collaborative improvement strategy improved IPC standards in our center, which can be easily replicated in other pediatric oncology centers in lower- and middle-income countries.

Pediatric Malignant Mediastinal Masses.

OBJECTIVE: To describe the clinical spectrum and outcome-associated variables of pediatric malignant mediastinal masses in a resource-limited setting. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Pediatric Hematology-Oncology, The Children's Hospital, Lahore, from October 2016 to November 2017. METHODOLOGY: Children with malignant mediastinal masses were enrolled. The variables studied were median age at presentation, gender distribution, immunisation status, socio-economic background, causes of delayed presentation, presenting complaints, complications of disease, methods for mass biopsy, final diagnosis, staging, and outcome of the disease. Results were described in terms of descriptive statistics. RESULTS: The median age at diagnosis was 7.5 years with male-to-female ratio of 2:1. The commonest presenting complaint was fever (82%), respiratory distress (58%), and lymphadenopathy (51%). Seventy-eight percent patients belonged to lower socio-economic class. Eighty-six percent of patients had delayed presentation to the tertiary care hospital and the most common reason was delayed diagnosis by the medical professionals (49%). Fifty-one percent patients had weight-for-age less than 5th percentile. Common complications were airway obstruction (35%), pericardial effusion (19.6%), superior vena cava syndrome and gross pleural effusion (13.7% each). Commonest diagnosis was T-cell acute lymphoblastic leukemia (35%) followed by lymphoblastic lymphoma and Hodgkin's lymphoma (15.7% each). Fourtyfive percent patients expired, 2% defaulted treatment and 5.9% completed treatment; 25% patients were under treatment, 3.9% patients had progressive disease while outcome of 17.6% of patients could not be known. The most significant factor associated with the outcome primary diagnosis (p<0.001), delayed presentation (p=0.007) and educational status of the family. CONCLUSION: The pattern of clinical presentation, complications and diagnoses of pediatric malignant mediastinal masses showed some variation from the already reported. Low literacy rate and delay in presentation are common and contribute significantly to the poor outcome.

Familial Hodgkin Lymphoma.

Hodgkin Lymphoma (HL) is a lymphoid tumour that represents about 1% of all neoplasms occurring worldwide. HLis the most treatable of childhood malignancies. The etiology of HLis unknown. However, increase risk has been reported in males, with autoimmune diseases, poor socioeconomic status, increased family size, Ebstein Barr Virus (EBV) exposure, congenital or acquired immunodeficiency and those with a family history of HL. Familial HLis rare. The risk of developing HLis increased six times in the siblings of the affected patients. Both genetic and environmental factors have been postulated in the pathogenesis. No case of familial HLhas been reported in the literature from Pakistan. We report two families with familial HLoccurring in siblings that have been successfully treated and are on our follow-up.