Echocardiographic based cardiac evaluation in children with severe acute malnutrition.

OBJECTIVE: To identify echocardiography-based myocardial changes in children with severe acute malnutrition. Methods: The prospective study was conducted from January to November 2020 at a territory care paediatric hospital in Multan, Pakistan, and comprised severe acute malnutrition patients of either gender aged 1-60 months and an equal number of matching healthy controls. Malnutrition was categorised using the World Health Organisation criteria. Echocardiographic evaluation was done by expert cardiologists. Values for ejection fraction shortening, left ventricular mass, E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions were noted. Data was analysed using SPSS 21. RESULTS: Of the 150 subjects, 75(50%) each were cases and controls. Age and gender were not significantly different between the groups (p>0.05). Left ventricular mass and left ventricular mass index with body surface area were significantly reduced in the cases compared to the controls, and the same was the case with left ventricular ejection fractional shortening (p<0.05). There was no significant difference between the groups in terms of E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions (p>0.05). Among the cases, cardiac evaluation showed 26(34.6%) were kwashiorkor and 49(65.3%) were marasmic patients. CONCLUSIONS: Left ventricular parameters in malnourished children were found to be reduced. As such, the assessment of these parameters may appear to be a significant indicator for timely identification of cardiac malfunction in severe acute malnutrition cases.

Developing neck circumference growth reference charts for Pakistani children and adolescents using the lambda-mu-sigma and quantile regression method.

OBJECTIVE: Neck circumference (NC) is currently used as an embryonic marker of obesity and its associated risks. But its use in clinical evaluations and other epidemiological purposes requires sex and age-specific standardised cut-offs which are still scarce for the Pakistani paediatric population. We therefore developed sex and age-specific growth reference charts for NC for Pakistani children and adolescents aged 2-18 years. DESIGN: Cross-sectional multi-ethnic anthropometric survey (MEAS) study. SETTING: Multan, Lahore, Rawalpindi and Islamabad. PARTICIPANTS: The dataset of 10 668 healthy Pakistani children and adolescents aged 2-18 years collected in MEAS were used. Information related to age, sex and NC were taken as study variables. The lambda-mu-sigma (LMS) and quantile regression (QR) methods were applied to develop growth reference charts for NC. RESULTS: The 5th, 10th, 25th, 50th, 75th, 90th and 95th smoothed percentile values of NC were presented. The centile values showed that neck size increased with age in both boys and girls. During 8 and 14 years of age, girls were found to have larger NC than boys. A comparison of NC median (50th) percentile values with references from Iranian and Turkish populations reveals substantially lower NC percentiles in Pakistani children and adolescents compared to their peers in the reference population. CONCLUSION: The comparative results suggest that the uses of NC references of developed countries are inadequate for Pakistani children. A small variability between empirical centiles and centiles obtained by QR procedure recommends that growth charts should be constructed by QR as an alternative method.

Stunting diagnostic and awareness: impact assessment study of sociodemographic factors of stunting among school-going children of Pakistan.

BACKGROUND: Stunting is a major public health issue in most of developing countries. Although, its worldwide prevalence is decreasing slowly but the number of stunted children is still rising in Pakistan. Stunting is highly associated with several long-term consequences, including higher rate of mortality and morbidity, deficient cognitive growth, school performance, learning capacity, work capacity and work productivity. To prevent stunting, we proposed Stunting Diagnostic and Education app. This app includes detailed knowledge of stunting and it's all forms, symptoms, causes, video tutorials and guidelines by the Pediatricians and Nutritionists. METHODS: A cross-sectional study has been conducted in schools of Multan District, Pakistan for the period of January 2019 to June 2019. Sample data of 1420 children, aged 4 to 18 years using three age groups, were analyzed by using SPSS version 21.0 to assess the prevalence of stunting and to analyze the risk factors associated with it in children under and over 5 age. Chi square test was applied in comparison with rural and urban participants and p-value < 0.05 was considered as significant. This study includes distribution of sociodemographic characteristics, parental education, working status of mothers, dietary patterns of school going children and prevalence of stunting in school going children. After getting study results, Stunting Diagnostic and Education app was developed according to the instructions of child experts and nutritionists. RESULTS: 354 (24.93%) participants were stunted out of 1420, 11.9% children were obese and 63.17% children were normal. Out of 354 stunted children, higher ratio of stunting was found in the age group of 8-11 years children with 51.98 percentage. 37.85% stunted children were found in the age group of 4-7 years and 10.17% stunting was found in the age group of 12-18 years children. It was observed in the study that male children were highly stunted than female with 57.91 and 42.09% respectively. Children living in rural areas were more stunted affected as compared to the children living in urban society with percentage 58.76 and 41.24 respectively. CONCLUSIONS: Our study concluded that 24.93% children were stunted, out of which, age group of 8-11 years children were highly stunted. The study showed that the literacy of mother or caregiver had high impact on children's health. Therefore, Stunting Diagnostic and Education app was developed to educate mothers to diagnose stunting and to teach about the prevention of stunting.

How childhood diseases awareness contributes to minimize the risk of disease severity in children under five age: An evolutionary study.

OBJECTIVE: To scrutinise the contribution of childhood disease awareness in mothers to minimise the risk of disease severity in children aged <5 years and to evaluate the effectiveness of a proposed app in this context. METHODS: The evolutionary study was conducted in Children's Hospital and the Institute of Child Health Multan from September 2018 to February 2019 and comprised two sessions with the app involving 30 mothers who were provided with smartphones with the app installed. The mothers were divided into 4 age groups. The app was evaluated using quantitative and qualitative measures. Suggestions and opinions were obtained in the first session and all suggestions were implemented by the second session. RESULTS: Of the 30 mothers, 8(26.6%) were in Group 1 aged 14-20 years, 12(40%) in Group 2 aged 21-27 years, 7(23.3%) in Group 3 aged 28-34 years and 3(10%) in Group 4 aged 35 years and above. The participants were able to diagnose their children's diseases accurately by following the instructions provided by the app. The subjects also agreed that they diagnosed the diseases accurately. All the participants were interested in the app and expressed the desire to have it available across the healthcare facilities in Pakistan. CONCLUSIONS: All subjects showed acceptance for the app and affirmed its easy usability, especially for illiterate mothers.

A descriptive study of double burden of malnutrition in mothers of children with severe acute malnutrition admitted in Children Hospital and Institute of Child Health, Multan.

OBJECTIVE: To assess the nutritional status of mothers of severely malnourished children, and to evaluate the factors associated with inadequate caloric intake of children with severe acute malnutrition versus sufficient caloric intake by mothers. METHODS: The cross-sectional descriptive study was conducted from January to June 2016 at Children Hospital and Institute of Child Health, Multan, Pakistan, and comprised mothers of severely malnourished children admitted for treatment. Data was collected using a questionnaire administered through interviews. Elements noted included body mass index, 24-hour recall, dietary restriction during pregnancy, lactation and complimentary feeding patterns of the children. The mothers were also examined for clinical signs of iron deficiency anaemia. RESULTS: Of the 100 women, 20(20%) were malnourished, 42(42%) were of normal weight, and 38(38%) were either overweight, pre-obese or obese. The caloric intake of 26(26%) mothers was less than 1500 kcal per day, while 42(42%) were taking between 2000-2500 kcal per day and 32(32%) were taking >2500 kcal daily. Also, 67(67%) women were suffering from anaemia and 80(80%) women had some myths related with dietary restrictions during pregnancy, lactation and complimentary feeding of children. Overall, 23(23%) women breastfed their babies.

Prognostic parameters of luminal A and luminal B intrinsic breast cancer subtypes of Pakistani patients.

BACKGROUND: Prognosis of breast cancer and success of therapeutic interventions largely rely on the clinico-pathologic and biological characteristics of the tumor and vary due to the heterogeneous nature of breast cancers. The aim of this study was to determine the frequency and prognostic parameters of luminal breast cancers in our population to devise targeted and personalized therapeutic regimens tailored to the needs of the loco-regional population. METHODS: A retrospective cross-sectional study including 1951 cases of primary breast cancer treated at Liaquat National Hospital Karachi was conducted during the year 2011-2016. The clinico-pathologic characteristics were observed and semiquantitative immunohistochemical analysis was performed to study the luminal subtypes A and B. The cross-tabulated statistics of the observed characteristics were performed between the two subtypes. The significance level of each characteristic was estimated utilizing the chi-square test. RESULTS: Luminal cancers comprised 62.7% of the total number of cases diagnosed with breast cancers in the study period. Out of these 1224 cases of luminal cancers, 845 cases (69%) were luminal B, while 379 (31%) cases were of luminal A. Luminal B cancers were significantly more common in younger age groups as compared to luminal A cancers. Comparison of the two subtypes of luminal breast cancers revealed significant differences. Luminal B cancers were associated with higher grade (26% grade III in luminal B compared to 8% in luminal A), micropapillary histology, and high frequency of nodal metastasis (54 vs. 43%). CONCLUSIONS: Luminal B comprised the most frequent subtype of breast cancer in our study and they were found more constantly in a younger age group. Moreover, they were associated with adverse clinico-histologic parameters like higher grade and nodal metastasis. Therefore, we suggest that, despite lack of widespread availability of molecular studies in our setup, IHC-based typing should be done in every case of breast cancer to individualize therapy.

Bridging Development and Disruption: Comprehensive Insights into Focal Cortical Dysplasia and Epileptic Management.

Focal cortical dysplasia (FCD) is a prominent neurological disorder characterized by disruptions in localized brain cell organization and development. This narrative review delineates the multi-faceted nature of FCD, emphasizing its correlation with drug-resistant epilepsy, predominantly in children and young adults. We explore the historical context of FCD, highlighting its indispensable role in shaping our comprehension of epilepsy and cortical anomalies. The clinical spectrum of FCD is broad, encompassing diverse seizure patterns, cognitive impairments, and associated neuropsychiatric disorders. We underscore the importance of differential diagnosis, with techniques ranging from electroencephalogram (EEG) interpretations to microscopic evaluations, and discuss advanced diagnostic modalities, such as the 3T magnetic resonance imaging (MRI) epilepsy protocols. Therapeutically, while anti-seizure medications are often first-line interventions, surgically refractory cases necessitate more invasive procedures, underscoring the importance of individualized treatment. Furthermore, the review touches upon the prognostic aspects of FCD, highlighting the importance of personalized care regimens, and provides insights into emerging therapeutic avenues, including the potential of the mammalian target of rapamycin (mTOR) pathway. Conclusively, this review accentuates the complex relationship between brain development and epileptogenicity inherent to FCD and underscores the promise of future research in enhancing patient outcomes.

Hepatic tumours in childhood: an experience at the Children Hospital and Institute of Child Health, Lahore.

OBJECTIVES: In this report, we share our experience about the common types of childhood hepatic tumours during 10 years (2001-2010) and compare them with other studies. METHODS: During 10 years (2001-2010), all the hepatic tumours of childhood received at Pathology Department of the Children Hospital and Institute of Child Health, Lahore Pakistan are recorded. This includes both resected specimens and biopsies. All the slides were reviewed and the pathologic diagnosis was confirmed. RESULTS: We diagnosed 48 liver tumour cases in children (below 18 years of age). Among these tumours, 39 (81.25%) were malignant. Male to female ratio was 2:1. Hepatoblastoma was the most common liver tumour in this age group accounting for 69.23% of all malignant tumours (27 cases). The second most common primary tumour was hepatocellular carcinoma diagnosed in six patients (15.38%). Other malignant tumours were undifferentiated embryonal sarcoma and biliary rhabdomyosarcoma. Benign tumours included mesenchymal hamartoma, infantile haemangioendotheloima, hemangioma and benign cyst. There were also three metastatic tumours during these 10 years. In one case there was tumour necrosis only and as such no definitive diagnosis was rendered. CONCLUSION: The spectrum of hepatic tumours in children is different from that found in the older age group and most of them are malignant.

EasyDetectDisease: An Android App for Early Symptom Detection and Prevention of Childhood Infectious Diseases.

BACKGROUND: Infectious diseases often lead to death among children under 5 years in many underdeveloped and developing countries. One of the main reasons behind this is an unawareness of disease symptoms among mothers and child caregivers. To overcome this, we propose the EasyDetectDisease mobile health app to educate mothers about the early symptoms of pediatric diseases and to provide them with practical advice for preventing the spread of such diseases in children under 5 years. The EasyDetectDisease app includes detailed knowledge of infectious diseases, including the corresponding symptoms, causes, incubation period, preventive measures, nutritional guidelines such as breastfeeding, video tutorials of child patients, and video guidelines by pediatric health experts to promote child health. It also provides information on the diagnosis of the infectious diseases based on symptoms. OBJECTIVE: The objective of this study was to evaluate the usability (eg, ease of use, easy detection of disease, functionality, and navigation of interfaces) of the EasyDetectDisease app among mothers of children under 5 years of age. METHODS: Two health sessions, held in Pakistan, were used to evaluate the usability of EasyDetectDisease by 30 mothers of children under 5 years. The app was evaluated based on various quantitative and qualitative measures. RESULTS: The participating mothers confirmed that they were able to diagnose diseases accurately and that after following the instructions provided, their children recovered rapidly without any nutritional deficiency. All participating mothers showed an interest in using the EasyDetectDisease app if made available by governmental public health agencies, and they suggested its inclusion in all mobile phones as a built-in health app in the future. CONCLUSIONS: EasyDetectDisease was modified into a user-friendly app based on feedback collected during the usability sessions. All participants found it acceptable and easy to use, especially illiterate mothers. The EasyDetectDisease app proved to be a useful tool for child health care at home and for the treatment of infectious diseases and is expected to reduce the mortality rate of children under 5 years of age.

Clinical Efficacy and Safety of Injectable Levetiracetam Versus Phenytoin as Second-Line Therapy in the Management of Generalized Convulsive Status Epilepticus in Children: An Open-Label Randomized Controlled Trial.

BACKGROUND AND PURPOSE: There is sparsity of quality evidence for the use of drugs after first-line benzodiazepines in convulsive status epilepticus in children. The aim of the study was to compare the clinical efficacy and safety of intravenous levetiracetam versus intravenous phenytoin as second-line drugs in the management of generalized convulsive status epilepticus in children. METHODS: This open-label randomized controlled trial was conducted in the Emergency Department of The Children's Hospital and The Institute of Child Health, Multan, Pakistan over a period of 4 years and 6 months from January 2014 to June 2018. This study included 600 children with generalized convulsive status epilepticus: 300 in the 40 mg/kg levetiracetam group, and 300 in the 20 mg/kg phenytoin group. Cessation of a clinical seizure (seizure cessation rate) within 30 minutes after the end of drug administration was the primary outcome in this study, and the presence or absence of adverse effects was noted as the secondary outcome. Data were analyzed using SPSS (version 20.0). RESULTS: The children in the levetiracetam and phenytoin were aged 3.5±0.2 and 3.4±0.2 years (mean±SD), respectively, their seizure durations before the start of treatment were 25.1±0.6 and 23.8±0.4 minutes, and their treatment efficacies were 278/300 (92.7%) and 259/300 (83.3%). Levetiracetam was significantly more effective than phenytoin (p=0.012), with no significant difference in safety. Adverse events were observed in eight children in the phenytoin group. CONCLUSIONS: Levetiracetam is significantly more effective than phenytoin for the treatment of convulsive status epilepticus in children who have failed to respond to benzodiazepines.

Ki67 index in intrinsic breast cancer subtypes and its association with prognostic parameters.

OBJECTIVES: Ki67 is the most commonly used marker to evaluate proliferative index in breast cancer, however no cutoff values have been clearly defined for high ki67 index. Cancer management should be according to loco-regional profile; therefore, we aimed to determine ki67 index in 1951 cases of intrinsic breast cancer subtypes and its association with other prognostic parameters in our set up. RESULTS: Triple negative breast cancers showed highest ki67 index (mean 50.9 ± 23.7%) followed by Her2neu (mean 42.6 ± 21.6%) and luminal B cancers (mean 34.9 ± 20.05%). Metaplastic and medullary breast cancers significantly showed higher ki67 index as compared to ductal carcinoma, NOS. No significant association of ki67 index was noted with any of the histologic parameters in different subtypes of breast cancer expect for tumor grade. Although, ki67 index is a valuable biomarker in breast cancer, however no independent prognostic significance of ki67 could be established in our study.

Clinical and prognostic profile of Her2neu positive (non-luminal) intrinsic breast cancer subtype: comparison with Her2neu positive luminal breast cancers.

OBJECTIVE: Her2neu receptor is proto-oncogene which can be over-expressed in both luminal and non-luminal breast cancers. In the present study, we aimed to compare the prognostic and predictive factors like tumor grade, T-stage, N-stage and ki67 index in Her2neu intrinsic breast cancer subtype with Her2neu over-expressed luminal breast cancers. RESULTS: 801 (41%) cases were Her2neu positive; out of which, 418 cases (52.2%) showed ER positivity and thus were classified as Her2neu positive luminal cancers whereas 383 cases (47.8%) were ER and PR negative and therefore were labeled as intrinsic Her2neu subtype (non-luminal). Her2neu positive (non-luminal) cancers were significantly associated with higher grades and Ki67 proliferative index compared to Her2neu positive luminal cancers. On the other no significant association was noted in T-stage and N-stage. We found a high frequency of her2neu positivity in our studied population of breast cancer. Moreover, association of her2neu positive (non-luminal) breast cancers with higher grade and ki67 index indicates a predictive value of ER/PR positivity in her2neu positive breast cancers. On the other hand, lack of association with respect to T and N stage, signifies no prognostic benefit of ER/PR in her2neu positive breast cancers.

Clinicopathologic features of invasive metaplastic and micropapillary breast carcinoma: comparison with invasive ductal carcinoma of breast.

OBJECTIVES: The aim of this study was to determine the frequency of metaplastic breast carcinoma and invasive micropapillary carcinoma in our population and also to compare the clinico-pathologic features of metaplastic breast carcinoma and invasive micropapillary carcinoma with invasive ductal carcinoma, not otherwise specified (IDC, NOS). RESULTS: 86.9% of the cases were identified as ductal carcinoma, NOS, while 2.2% were metaplastic and 0.76% cases were micropapillary carcinoma. Metaplastic carcinomas were found to be of higher grade as compared to IDC, NOS as 81% of metaplastic carcinoma were grade III compared to 35% IDC, NOS. 79% of metaplastic carcinoma were ER negative and 86% were PR negative, respectively as compared to ductal carcinoma NOS, which were 40% ER negative and 54% were PR. Similarly, 86.7% micropapillary cancers were ER positive and 73.3% were PR positive. Moreover, 66.7% micropapillary carcinoma showed nodal metastasis and 77.8% showed lymphovascular invasion, which was significantly higher than that of IDC, NOS micropapillary and metaplastic carcinomas accounts for less than 2 and 1% of the breast cancer burden in our population and highly correlates with poor prognosis parameters therefore, require more intensive management in our population.