Single Nucleotide Polymorphisms Of Transforming Growth Factor-Β1 Gene As Potential Asthma Susceptible Variants In Punjabi Population Of Pakistan.

Background: Candidate gene approach based on case-control model is a valuable strategy to determined disease related genetic variants. Two single nucleotide polymorphisms rs1800469 and rs2241715 in TGF ß1gene have been reported to affect the asthmatic status in different populations. The main focus of this research was to find any relationship between these SNPs and asthma in Pakistani population. Methods: Using case-control model, a total of 108 individuals including 52 asthma patients and 56 healthy controls were screened to find asthma susceptibility of variants rs1800469 and rs2241715. These SNPs were genotyped using SNaPshot minisequencing assay followed by capillary electrophoresis using ABI 3130xl genetic analyzer platform. The statistical analysis of genetic data was performed by using SPSS 21, SHEsis online platform and SNPStats online web software. Results: No association with asthma was seen in allelic model for both SNPs but genotypes analyzed under codominant, dominant, over dominant and recessive models of inheritance revealed that SNP rs2241715 is strongly associated with asthma under genotypic model. Conclusion: rs2241715 was found to be a genetic risk factor for asthma in Pakistani population.

Association of Blood Groups with the Severity and Outcome of COVID-19 Infection in Children.

The objective of this study was to find out the association of ABO blood groups with the severity and outcome of corona virus disease 2019 (COVID-19) in children. It included all laboratory-confirmed cases of COVID-19 and post-COVID multisystem inflammatory syndrome in children (MIS-C)/ Kawasaki disease (KD) like illness, admitted from March to September, 2020 to The Children's Hospital, Lahore. Out of 66 children, 45 (68.2%) were COVID-19 and 21 (31.8%) MIS-C/KD temporally associated with SARS-C0V-2. The mean age was 7.9 ± 4.2 years. Majority of children had mild to moderate illness 38 (57.6%), while 23 (34.8%) had severe or critical disease. Among all patients, 24 (36.4%) had some underlying comorbidity. Blood group A was significantly associated with severe and critical disease (p=0.030). COVID-19 in children had generally a good outcome, but children with blood group A were more susceptible to severe/critical disease. Key Words: Coronavirus disease 2019, ABO blood groups, Children, Severity, Outcome.

Appraisal of anti-mycobacterial potential against MDR-MTB in pediatric patients, cytotoxicity and mutagenicity of Aloe vera and Allium sativum.

The purpose of the studies was to evaluate an in-vitro anti-mycobacterial activity of Aloe vera and Allium sativum against MDR-MTB, their cytotoxicity and mutagenicity. Four extracts of Aloe vera and Allium sativum were prepared by Soxhlet apparatus and their minimum inhibitory concentrations (MIC's) were determined by BACTEC MGIT960 system against multi drug resistant Mycobacterium tuberculosis (MDR-MTB) isolates, collected from pediatric patients. Fractions of Aloe vera and Allium sativum extracts were separated using glass column chromatography, followed by evaluation of cytotoxicity and mutagenicity by tetrazolium salt (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and Ames test, respectively. Out of four extracts, ethanol extracts of Aloe vera and Allium sativum exhibited activity at MIC 5mg/mL to 7mg/mL and 3mg/mL to 5mg/mL, respectively and IC50 by MTT assay for combination of all fractions were 278.3mcg/100µL and 270.8mcg/100µL and in Ames assay M.I of TA98 were 0.14 and 0.07 and M.I of TA100 were 1.14 and 0.44, respectively. Aloe vera and Allium sativum extracts showed anti-mycobacterial activity against MDR-MTB isolates so, MIC of ethanol extracts of each plant and fractions of column chromatography had been checked. The MTT and Ames tests depicted that ethanol extracts of Aloe vera and Allium sativum were non-cytotoxic and non-mutagenic, and can be used in treatment of patients suffering from MDR-MTB.

Is leukopenia and lymphopenia a characteristic feature of COVID-19 in children?

OBJECTIVES: To analyze whether leucopenia and lymphopenia a characteristic feature of children with COVID-19 and to find out its association with the disease severity. METHODS: This was a descriptive cross-sectional study conducted at The Children's Hospital Lahore from March 2020 to October 2020. All confirmed cases of COVID-19 infection and post-COVID MIS-C/Kawasaki Disease diagnosed on the basis of RT-PCR and Antibody test respectively were included. Complete blood and differential counts were performed on the day of admission. RESULTS: Out of a total of 83 patients 60 (72%) were diagnosed as COVID-19 and 23 (28%) as post-COVID MIS-C/KD. The mean age of children was 7.0±4.3 years (95%CI: 6.07 - 8.75) with a male preponderance 51 (61%). Twenty (24%) children had an underlying comorbidity and 7 (8%) were surgical cases. Our case fatality rate was 5 (6%) and all children who died had an underlying comorbid condition. In both, COVID and MIS-C/KD the mean leukocyte count was (14.0 ± 12.5 vs 13.6 ± 6.9 x109/L), respectively (p=0.888). The mean lymphocyte count in children with COVID was (39.1 ± 21.4%). Patients with MIS-C/KD showed significantly higher levels of neutrophil count (76.5 ± 15.0%) as compared to children with COVID (52.0 ± 22.1%), absolute lymphocyte count was (5.02±4.81 vs 2.13±0.95 x109/L) in COVID and MIS-C respectively (p=<0.001). In 60 COVID-19 patients, the mean neutrophil lymphocyte ratio (NLR) in mild-moderate and severe-critical group was 2.00 and 5.08 respectively (p=0.009). CONCLUSION: The blood picture of COVID-19 in children does not show leukopenia. NLR was a prognostic factor to assess the severity in COVID-19 patients. The presence of an underlying comorbid conditions is significant a risk factor for poor outcome.

Association of Blood Groups with the Severity and Outcome of COVID-19 Infection in Children.

The objective of this study was to find out the association of ABO blood groups with the severity and outcome of corona virus disease 2019 (COVID-19) in children. It included all laboratory-confirmed cases of COVID-19 and post-COVID multisystem inflammatory syndrome in children (MIS-C)/ Kawasaki disease (KD) like illness, admitted from March to September, 2020 to The Children's Hospital, Lahore. Out of 66 children, 45 (68.2%) were COVID-19 and 21 (31.8%) MIS-C/KD temporally associated with SARS-C0V-2. The mean age was 7.9 ± 4.2 years. Majority of children had mild to moderate illness 38 (57.6%), while 23 (34.8%) had severe or critical disease. Among all patients, 24 (36.4%) had some underlying comorbidity. Blood group A was significantly associated with severe and critical disease (p=0.030). COVID-19 in children had generally a good outcome, but children with blood group A were more susceptible to severe/critical disease. Key Words: Coronavirus disease 2019, ABO blood groups, Children, Severity, Outcome.

Perspective of health professionals on hand hygiene in a tertiary care center in Pakistan.

OBJECTIVE: To determine the awareness of postgraduate residents and nurses working in a tertiary care hospital about hand hygiene. METHODS: The cross-sectional study was conducted in October 2018 at The Children's Hospital and the Institute of Child Health, Lahore, Pakistan, and comprised postgraduate residents and nurses. Data was collected using a 31-item self-administered inventory. Data analysis was done using SPSS 21. RESULTS: Of the 360 subject, 152(42.2%) were postgraduate residents and 208(57.8%) were nurses. Overall score of knowledge 202(56%) was low compared to attitude 260(72%) and practice 283(78.6%). The combined score of all three domains was 245(68%), indicating moderate awareness. Postgraduate residents had significantly better knowledge 98(64%) compared to nurses 104 (50%) (p=0.01), while nurses had better attitude score 159(76.4%) compared to the residents 103(68%) (p<0.05). The practice subscale score was not significantly different between the groups (p>0.05). CONCLUSIONS: Both postgraduate residents and nurses showed moderately satisfactory knowledge, attitude and practice towards hand hygiene.

Major histocompatibility complex class II polymorphic variants are associated with asthma predisposition in the Punjabi population of Lahore, Pakistan.

INTRODUCTION: Various genome wide association studies have manifested that Major Histocompatibility Complex (MHC) region on chromosome 6p21 houses many potential candidate genes for asthma. OBJECTIVE: This Case-Control association study was planned to determine the association of 10 Single Nucleotide Polymorphisms (SNPs), residing within and around MHC genes' region on chromosome 6p21, with Asthma in Punjabi population of Lahore, Pakistan. METHODS: A total of 161 subjects, 61 physician-diagnosed asthma patients and 100 age-matched healthy controls, were recruited from Lahore, a city in Punjab. Ten single nucleotide polymorphisms (SNPs) (rs9378249, rs2070600, rs404860, rs6689, rs1049124, rs1063355, rs1049225, rs1049219, rs7773955 and rs928976) located within or near AGER, NOTCH and HLA genes in MHC region, were genotyped in both patients and controls using single base extension reaction and capillary electrophoresis-based genetic analyser. Statistical models were applied using SHEsis Plus. Results were adjusted for various cofactors (age, gender and environment) and by applying multiple corrections. Haplotype and linkage disequilibrium analyses were performed on Haploview software v4.1. RESULTS: Three of the studied SNPs rs1049124, rs1049219 and rs7773955 show independent significant association with asthma under allelic and genotypic models. Two of the haplotypes, H7 and H13, "CTAATTT" and "CCACTAT", respectively, for rs2070600, rs404860, rs6689, rs1049124, rs1063355, rs1049219 and rs7773955, are found to be significantly associated with the disease. CONCLUSION: This study reports association of SNP variants residing on HLA-DQB1 and HLA-DQA2 genes and haplotypes H7 and H13 on genomic region 6p21 with Asthma in the Punjabi population of Lahore, Pakistan.

Evaluation of ADAM33 gene's single nucleotide polymorphism variants against asthma and the unique pattern of inheritance in Northern and Central Punjab, Pakistan.

OBJECTIVES: To investigate the relationship of 3 single nucleotide polymorphism (SNP) variants of ADAM33 with asthma susceptibility in patients from Northern and Central Punjab, Punjab, Pakistan. Methods: In this case-control study, healthy and asthmatic participants were recruited between 2015 and 2017. The SNPs of ADAM33 gene, rs2280089, rs2280090, and rs2280091 were analyzed in 296 asthma patients and 343 healthy controls, as well as linkage disequilibrium and haplotype analysis. RESULTS: The non-significant differences were observed in allele and genotype frequencies of the SNPs in asthmatic and healthy persons even after population stratification based on age, caste, gender, family history, and environment. Although these SNPs were non-significant for disease susceptibility among children and adults, a fixed unique pattern of inheritance was nevertheless observed for the studied SNPs. Linkage disequilibrium analysis presented a very strong linkage between the SNP variants to predict their co-inheritance in study population. However, none of the haplotypes were found to be associated with asthma disease development. CONCLUSION: The studied SNPs of ADAM33 appeared to be non-significant for asthma susceptibility in  Northern and Central Punjabi population. The fixed allele combination inheritance pattern was a unique observation contrary to findings in other global populations.

Shprintzen-Goldberg Syndrome: A Rare Disorder.

The Shprintzen-Goldberg syndrome (SGS) or velo-cardio-facial syndrome (VCFS) is an extremely rare disorder of connective tissue with a characteristic facial dysmorphism, marfanoid features, craniosynostosis, dolichocephaly, cardiovascular anomalies and mild to moderate mental retardation. It may be a de novo gene mutation or inherited as an autosomal dominant disorder having SKI gene and Fibrillin-1 gene (FBN1) mutations, located on chromosome 15q21.1. We report a case of a 3-month, developmentally delayed male infant admitted to the hospital with syndromic facies, craniosynostosis, joint laxity and on echocardiography, aortic root dilatation. A probable diagnosis of SGS was made on the clinical grounds. We did not have the facility for genetic chromosomal analysis. He was discharged with family counselling and follow-up for future developmental rehabilitation.

Burnout among pediatric residents and junior consultants working at a tertiary care hospital.

OBJECTIVE: To determine the burnout among postgraduate residents' and junior consultants in a tertiary care hospital. METHODS: This cross-sectional study was conducted among the postgraduate residents (PGR) and junior consultants (JC) working at The Children's Hospital Lahore in 2018. Participants were asked to complete Copenhagen Burnout Inventory questionnaire about burnout on 5 point Likert scale. '100 (always), 75 (often), 50 (sometimes), 25 (seldom) and 0 (never/almost never or according to intensity ranging from 'a very low degree' to 'to a very high degree'. Data was analyzed using SPSS version 22. Three questions were added related to hospital factors but scored separately. Students t-test and chi square test were used to compare the burnout. RESULTS: A total of 227 participants including 177 PGR and 50 JC completed the questionnaire with a response rate of 84% and 86% respectively. There was a female predominance, 140 participants (61.7%) were female. Majority was from pediatric medicine 173 (76.2%). The mean personal and work related-burnout was high among PGRs as compared to JCs (18.68±5.01vs 16.62±4.57) (p=0.008) and (21.14±5.57 vs. 18.56±5.52) (p=0.004) respectively. Similarly, there was significantly more burnout among pediatric medicine study participants as compared to surgery and diagnostic in all domains (personal BO; p=0.030, work-related BO; p=0.021, patient related BO; 0.033 and hospital related BO; 0.001). No difference were noted based on gender and year of training. CONCLUSION: Tertiary care hospital postgraduate residents and junior consultants face moderate burnout. Postgraduate residents had significantly more burnout as compared to junior consultants and majority was from pediatric medicine.

Spectrum of complications in childhood Enteric Fever as reported in a Tertiary Care Hospital.

OBJECTIVE: To find out frequency of various complications in children admitted with Enteric Fever at a tertiary care hospital. METHODS: This was prospective cross sectional study, carried out in the Pediatric Medicine department of The Children's Hospital Lahore from Dec 2014 to March 2017. Children of both genders with age range of 6 months to 16 years diagnosed as enteric fever on the basis of clinical features and positive Typhidot, or blood culture were included in the study. All 180 patients were scrutinized for all possible complications. Where ever required and feasible appropriate and relevant investigations were done to document complications. Data was analyzed by SPSS version 20. RESULTS: Mean age of children was 7.2±3.38, majority 94 (52.2%) were 5-10 years old. Out of 180 patients, complications were noted in 58 (32.2%). Neurological complications 30.7% encompassed maximum complications followed by hepatobiliary 24.61%, abdominal 16.92% hematological 9.23%, bone and joints 7.69%, respiratory system 6.1% and cardiovascular system 4.41%. Mortality rate was 1.6%. Thrombocytopenia and leucopenia were significantly associated with complications with p value of 0.002 and 0.003 respectively. CONCLUSION: Enteric fever is causing our children to suffer by its numerous perplexing and fatal complications. The most vulnerable age for enteric fever and its complication is 5-10 years. To combat these issues large scale vaccination remains promising option at least in most susceptible age group.

Adherence to asthma treatment and their association with asthma control in children.

OBJECTIVE: To assess the degree of medication adherence among asthma patients and association of asthma control level with the degree of adherence. METHODS: This descriptive cross-sectional study was conducted at The Children's Hospital and The Institute of Child Health, Lahore, Pakistan, from January to December 2015, and comprised persistent asthma patients. Medication adherence in these paediatric subjects was assessed by using Morisky medication adherence assessment questionnaire. Children were categorised using Global Initiative for Asthma guidelines as having well-controlled, partially-controlled or uncontrolled asthma. Data was analysed using SPSS 16. RESULTS: Out of 310 subjects, 202(65%) were male and 108(34.83%) were female. The overall mean age was 8.9±3.5 years. Of the total, 66(21.3%) had well-controlled asthma, 71(22.9%) partially-controlled and 173(55.8%) uncontrolled. Low adherence was found in 138(44.5%) subjects, medium adherence in 71(22.9%), and high adherence in 101(32.6%). High adherence was significantly associated with well-controlled asthma (p<0.05). CONCLUSIONS: Adherence with medication regimen was found to be necessary for obtaining maximum therapeutic benefits in children with asthma.

A Rare Case of Kikuchi-Fujimoto Disease Associated with Systemic Lupus Erythematosus.

Kikuchi-Fujimoto Disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a self-remitting, immune-mediated rare disorder having unique histopathological characteristics which is commonly seen in young Asian females, but can occur in all ethnicities. There is a strong association between KFD and Systemic Lupus Erythematosus (SLE). We present a case of a young Pakistani boy who presented with cervical lymphadenopathy, fever, blackish discoloration of finger tips, and Raynaud's phenomenon. His lymph node biopsy was suggestive of KFD. The American Rheumatology Association diagnostic criteria were not met as no other features of SLE were present. His autoimmune workup including Anti-Nuclear Antibodies (ANA) and Anti-Double Stranded DNA (Anti-Ds DNA) antibodies were positive and supported the diagnosis of SLE. He improved clinically with steroid therapy and nifedipine with resolution of symptoms.

Patient safety awareness among postgraduate students and nurses in a tertiary health care facility.

OBJECTIVE: To determine the knowledge of patient safety among postgraduate residents (PGR) and nurses in a tertiary care hospital. METHODS: This casual comparative study was conducted among the postgraduate residents and nurses working at The Children's Hospital Lahore in the month of July, August 2017. Both PGR and nurses were asked to complete APSQ-IV questionnaire about patient safety on 7 point Likert scale. Data was analyzed using SPSS version 20 and t-test was used to compare the mean score between two groups. The names of the participants were kept confidential. RESULTS: A total of 150 residents and 150 nurses were included. The scores of both postgraduate residents and nurses were similar in all domains having positively worded questions with insignificant difference in mean score (p=0.141). In the reverse coded questions the nurses showed positive perception with higher mean score as compared to postgraduate residents (p=0.004). The postgraduate residents in the early years of residency had higher mean score in positively worded question as compared to residents who were in last years of training (p=0.006). There was no difference in the mean score of nurses as regard to their years of experience (p=0.733). Medical error disclosure domain was reported lowest by both postgraduate residents and nurses. CONCLUSION: Both postgraduate residents and nurses showed positive attitude with good knowledge and perception towards patient safety. Lowest rated scores were from error disclosure confidence domain.

rs12603332 is associated with male asthma patients specifically in urban areas of Lahore, Pakistan.

OBJECTIVE: rs12603332, an important regulatory site variant, is known to alter the regulatory motif E2A that is involved in the maturation of B-lymphocytes. The study was designed to check whether different environmental exposures alter its risk allele association with asthma or not. METHODS: 200 Physician-diagnosed asthma patients and 108 healthy individuals were enrolled from hospitals of Lahore. After quantitation of DNA extracted from peripheral blood, amplification of genomic region with rs12603332, followed by single base extension (SBE), was performed. Allele and genotype frequencies were calculated by SHEsis and Haploview software packages. Statistical analyses on PLINK were also performed, taking different factors as covariates. HaploReg analysis was done to predict the effect of risk allele on different regulatory motifs. RESULTS: Risk allele for rs12603332 i.e., "C" allele was found to be significantly associated with male patients residing in urban localities. CONCLUSION: The finding suggests that on exposure with urban environment, risk allele carriers tend to develop asthma symptoms via epigenetic regulation of motif associated with maturation of B-lymphocytes.

Impact of maternal education, employment and family size on nutritional status of children.

OBJECTIVE: To determine the impact of maternal education, employment, and family size on nutritional status of children. METHODS: It was case control study conducted at OPD of children Hospital Lahore, from September 2015 to April 2017. Total 340 children (170 cases and 170 controls) with age range of six months to five years along with their mothers were included. Anthropometric measurements were plotted against WHO growth Charts. 170 wasted (<-2 SD) were matched with 170 controls (≥ -2 SD). Maternal education, employment and family size were compared between the cases and control. Confounding variables noted and dichotomized. Univariate analysis was carried out for factors under consideration i.e.; Maternal Education, employment and family size to study the association of each factor. Logistic regression analysis was applied to study the independent association. RESULTS: Maternal education had significant association with growth parameters; OR of 1.32 with confidence interval of (CI= 1.1 to 1.623). Employment status of mothers had OR of 1.132 with insignificant confidence interval of (CI=0.725 to 1.768). Family size had OR of one with insignificant confidence interval (CI=0.8 -1.21). Association remained same after applying bivariate logistic regression analysis. CONCLUSION: Maternal education has definite and significant effect on nutritional status of children. This is the key factor to be addressed for prevention or improvement of childhood malnutrition. For this it is imperative to launch sustainable programs at national and regional level to uplift women educational status to combat this ever increasing burden of malnutrition.

Genetic variants of ADAM33 are associated with asthma susceptibility in the Punjabi population of Pakistan.

OBJECTIVE: A disintegrin and metalloproteinase 33 (ADAM33) gene has been considered as an asthma susceptibility gene due to its possible role in airway remodeling, abnormal cell proliferation, and differentiation. Association of this gene with asthma has been reported in several genetic studies on various populations. The current study aims to evaluate the association of ADAM33 gene polymorphisms with the risk of asthma in the Punjabi population of Pakistan. METHOD: A total of 101 asthma patients and 102 age-matched healthy controls from Lahore, a city in Punjab, were recruited. ADAM33 single nucleotide polymorphisms (SNPs) T + 1[rs2280089], T2[rs2280090], T1[rs2280091], ST + 5[rs597980], ST + 4[rs44707], S2[rs528557], Q - 1[rs612709], and F + 1[rs511898] were genotyped in both patients and controls using single base extension and capillary electrophoresis-based genetic analyzer. The basic allelic and genotypic model was analyzed for association of the SNPs with asthma using SHEsis software. Haploview software was used to calculate pairwise linkage disequilibrium (LD) among six of the genotyped SNPs. RESULTS: Of the 8 SNPs genotyped, only S2[rs528557] showed significant association with asthma (Allele p = 0.0189, Genotype p = 0.021). SNPs T + 1[rs2280089], T2[rs2280090], T1[rs2280091], ST + 4[rs44707], S2[rs528557], and Q - 1[rs612709] were found to be in moderate to strong LD. The significantly higher frequency of haplotype "AAGTCG" in healthy controls suggests a protective effect against asthma risk in the studied population (p = 0.0059). CONCLUSION: These findings suggest that genetic variants of ADAM33 gene may play important roles in asthma susceptibility in the Punjabi population of Pakistan.

Sequence variants on 17q21 are associated with the susceptibility of asthma in the population of Lahore, Pakistan.

OBJECTIVE: Single nucleotide polymorphisms (SNPs) on 17q21 are known to be associated with asthma disease in multiple populations. This study was designed to know whether this region is associated with asthma in Lahore region population or not. METHODS: A total of 200 asthma patients and 100 healthy controls were enrolled from different hospitals of Lahore, Pakistan. Twelve SNPs from chromosomal region 17q21 were analyzed in cases and controls by single base extension method and capillary-based genetic analyzers. Associations with asthma were checked using basic allelic model, genotypic model, and results were adjusted by logistic regression analysis using PLINK v1.9. Pair-wise linkage disequilibrium among the SNPs was analyzed by using Haploview software. RESULTS: SNP rs3816470 showed a strong association (p = 8.89 × 10(-5), Odd Ratio = 3.082 [1.755-5.41]) with asthma, whereas rs3859192 and rs6503525 also showed a significant association with the development of asthma, especially in the case of positive family history. In LD block1 (93 kb) consisting of six SNPs (rs12936231, rs7216389, rs7216558, rs9894164, rs1007654 and rs7212938), none of the haplotypes show any significant association with asthma except the haplotype "CCTCAG", which is a significant protective factor against asthma having frequency 0.051 in controls while 0.017 in cases (p = 3.56 × 10(-2), χ2 = 4.415). CONCLUSION: The present study reports that the polymorphic genomic variant rs3816470 is significantly and independently associated with asthma in the studied population, while the variants, rs6503525 and rs3859192, also indicate a significant association with asthma in this population when family history of the disease is taken as a covariate.