COVID-19 in children: Epidemiology, presentation, diagnosis and management.

The new pandemic coronavirus disease (COVID-19) has affected children, including neonates, who mostly comprise of approximately 2% of total confirmed cases. Most children are asymptomatic or have mild disease and much lower mortality compared to adults for yet unknown reasons. Recovery from illness has largely been universal and <2% have severe disease requiring intensive care. Standardised guidelines from initial studies are now available for diagnosis, treatment, and prevention. Treatment is mostly supportive with no recommendations for any specific drugs so far. As the pandemic evolves, it is expected that more children will be diagnosed and treated with evolving newer regimens. Research should now focus on early diagnosis, better drugs for children, intensive care modalities, and a universal vaccine. New developments will help in better prevention asides from the other precautionary measures already being practiced.

An Overview of Extensively Drug-resistant Salmonella Typhi from a Tertiary Care Hospital in Pakistan.

INTRODUCTION:  Since 2016, the province of Sindh is in the limelight because of its association with the emergence and spread of extensively drug-resistant Salmonella typhi (XDR S. typhi). Although its global spread has been proven in several studies, our information regarding its countrywide existence is still insufficient. In the last four years, few cases of XDR S. typhi were identified at the Shifa International Hospital (SIH), Islamabad, Pakistan. This article aims to report demographic patterns, clinical presentations, and treatment outcome of these cases. MATERIALS AND METHODS:  This study was conducted at SIH, Islamabad, on blood culture-proven XDR S. typhi cases from January 2015 to December 2018. The data were retrieved from the hospital's record system. Patient demographic details, clinical presentations, management, and disease outcomes were evaluated and statistical analysis was performed through IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY). RESULTS:  A total of 30 blood culture-proven XDR S. typhi cases were identified and 80% (24) of them were reported in 2018. The mean age at presentation was 12.8±9.6 years. Twelve (40%) patients came from Islamabad, nine (30%) from Rawalpindi, and eight (26.6%) from Khyber Pakhtunkhwa (KPK). All patients, except one, were prescribed meropenem and azithromycin. Three patients developed complications but no mortality was documented. Over four years, these XDR S. typhi cases contributed 5.01% to the total S. typhi isolates. CONCLUSION: This study validates the existence of XDR S. typhi all over Pakistan. It stresses upon the fact that more stringent methods should be adopted for its identification and control.

RISK CHARACTERIZATION OF MATERNAL AND NEONATAL TETANUS IN VIEW OF TETANUS VACCINATION CAMPAIGNS IN PAKISTAN.

BACKGROUND: Pakistan is one of the remaining 24 countries which have not yet achieved Maternal and Neonatal Tetanus Elimination (MNTE), The country adopted high-risk approach for 56 out of 119 districts with country-wide Tetanus Toxoid (TT) provision in Routine Immunization (RI) during early 2000-2003. The TT's mass campaigns could only cover 13% of high risk districts for 2009- 2011, and mostly for the Punjab province. To achieve MNT elimination, the country needs risk mapping for cost-effective intervention. METHODS: We used both the quantitative and qualitative methods to conduct risk characterization. All the three available data sets (Reported EPI coverage data, PDHS 2012-13, and PSLM 2010-11) were assessed. A mix of core and surrogate indicators-for risk categorization was used through ranking and scoring the aggregated data and considering the past tetanus campaigns' coverage. Tetanus Toxoid (TT2+)-coverage of pregnant women and delivery in health facility, both received more weightage in scoring. We based the higher and lower cuts off points for each indicator on data ranges. The districts with higher scores, i.e., 10.5 and above were ranked good followed by medium (5.5-10.4) and low performing (less than 5.5). Consultations with the national and provincial field officers were utilized to understand the local context. RESULTS: In Pakistan, there are 139 districts out of which, 60 are the high risk districts for tetanus. Highest percentage is for Baluchistan (83%) followed by Sindh (52%), and Khyber Pakhtunkhwa (40%). Most of the Punjab is at medium risk (55%), followed by KP (52%), and Sindh (39%). CONCLUSION: Pakistan is at medium to high risk of MNT with a great variation at the sub-national level. Campaigns aiming to these districts may bring the country closer to MNT elimination target.

Antenatal Bartter syndrome.

Antenatal Bartter syndrome is characterized by severe polyhydramnios in mother leading to premature delivery. Antenatal treatment has proven effective to prevent these problems. Postnatally newborns suffer from recurrent episodes of severe dehydration and electrolyte imbalance which can lead to fatal outcome. These manifestations are likely to be overlooked and missed under the umbrella of diagnosis of prematurity. This premature newborn with antenatal polyhydramnios had severe manifestations of polyuria, recurrent dehydration, electrolyte derangements and metabolic alkalosis. She was managed accordingly but unfortunately could not survive beyond 4 weeks.

Susceptibility and irritability of adult forms of main malaria vectors against insecticides used in the indoor residual sprays in Muzaffargarh District, Pakistan: a field survey.

In southern Punjab, Pakistan, Muzaffargarh District is known to have insecticide-resistant Anopheles and drug-resistant Plasmodium spp. In this part of the country, five anopheline mosquitoes, Anopheles stephensi Liston, Anopheles culicifacies Giles, Anopheles fluviatilis James, Anopheles superpictus Grassi, and Anopheles subpictus Grassi (Diptera: Culicidae) are known as malaria vectors. Among these, An. culicifacies is the primary and An. stephensi is the secondary malaria vector. Outbreaks of malaria usually occur after rainy episodes. We conducted field surveys to collect field strains of An. culicifacies and An. stephensi mosquitoes from different areas of Muzaffargarh District. We determined susceptibility and irritability levels of their adult stages to the discriminative dose of different insecticides. For this purpose, we used World Health Organization's established criteria for assessment. Mortality was calculated after 1 h exposure and for 24 h recovery period for various insecticides. An. stephensi was found to be significantly resistant to dichlorodiphenyltrichloroethane (DDT, an organochlorine), dieldrin (a chlorinated hydrocarbon), and malathion (organophosphorus), with lethal times (LT50) of 83.17, 52.48, and 37.53, respectively. However, the species was significantly sensitive to permethrin, deltamethrin (pyrethroids), and fenitrothion (organophosphate) with LT50 of 2.85, 2.34, and 13.18, respectively. Among these, permethrin showed more promising results against adult An. stephensi. When analyzed for irritancy, we found that among pyrethroids, permethrin was the most irritant insecticide for both An. stephensi and An. culicifacies. DDT and dieldrin showed least irritancy with 0.42 +/- 0.08 and 0.77 +/- 0.12 takeoffs per minute per adult, respectively, against An. stephensi. The mean number of takeoffs per minute per adult with permethrin showed significant irritancy for permethrin when compared with DDT. Based on this study, we conclude that the use of organochlorine (DDT) and chlorinated hydrocarbon (dieldrin) should not be reintroduced in Malaria Control Programme in Pakistan until there is enough evidence to do so at any stage in future, and the use of pyrethroids should continue, with preference to permethrin for better control of malariaby indoor residual spraying.

Posterior sagittal approach for resection of sacrococcygeal teratomas.

The aim is to evaluate the ease of access, surgical trauma and cosmetic results of posterior sagittal approach for sacrococygeal teratomas (SCTs). From January 2002 to June 2010, we operated 19 cases of SCT exclusively through posterior sagittal approach. Patients were placed in knee chest position. An elliptical incision was made for the excision of the tumor. Care was taken to preserve all the muscles and other vital tissue in this area. Coccygectomy was performed in all patients. Closure was performed in layers. It was possible to resect all tumors from this approach and none of the patients required revision of the incision. Complete resection was possible in 17 patients while two had residual disease due to local extension. Minimal wound dehiscence was noted in four patients that healed spontaneously. It was possible to perform excision even in very large masses. Wound scar was satisfactory in most patients with preservation of gluteal folds. It is therefore concluded that posterior sagittal approach for SCT is feasible, with good access and cosmetic results.