Comparison of risk factors for Methicillin Resistant Staphylococcus aureus (MRSA) colonization in healthy newborns, born to mothers with and without MRSA colonization.

Objective: To compare the risk factors for MRSA colonization in healthy newborns, born of mothers with and without MRSA colonization. Methods: This case control study was conducted in post-natal unit of Lady Willingdon Hospital, affiliated with King Edward Medical University/Mayo Hospital, Lahore from January to June 2017. The vaginal and anterior nares swabs for MRSA culture were collected from mothers within six hours before planned delivery and the neonatal anterior nares swabs for MRSA culture were taken within one hour of birth. All the samples were cultured in Paediatric Microbiology laboratory in Mayo Hospital. Data were analyzed through SPSS 20.0 and logistic regression was applied for risk factors analysis. Results: Out of total 80 mothers and their newborns, 15 (18.75%) mothers and 16 neonates (20%) were MRSA colonized. The frequency of MRSA colonization in mothers' anterior nares and vaginal swab was 17.5% and 1.25% respectively. The significant risk factors were prolonged rupture of membranes for >18 hours (p-value 0.02, odds ratio 11.85, 95% CI 1.41-99.3), birth weight <2500 grams (p-value 0.01, odds ratio 5.39, 95% CI 1.35-21.4), history of presence of meconium (p-value 0.006, odds ratio 7.30, 95% CI 1.78-29.8). The non-significant factors were age of mother (p-value 0.682, odds ratio 0.765, 95% CI 1.0.212-2.76), parity (p-value 0.185, odds ratio 3.82, 95% CI 0.46-31.66) , gestation (p-value 0.615, odds ratio 0.797, 95% CI 0.714-0.89) , mode of delivery (p-value 0.576, odds ratio 0.543, 95% CI 0.062-4.76), sex of baby (p-value 0.546, odds ratio 0.683, 95% CI 0.196-2.37) and presentation of baby at birth (p-value 0.47, odds ratio 0.795, 95% CI 0.71-0.89). Conclusion: The presence of meconium, prolonged rupture of membranes and low birth weight were the significant risk factors for MRSA colonization in healthy new-borns, born to mothers with and without MRSA colonization.

Post-graduate educational environment of two parallel programs in Pediatric Medicine.

Objective: To compare the trainees' perception of the Educational Environment (EE) of the two parallel post-graduate training programs (MD & FCPS) in Pediatric Medicine. Methods: This quantitative cross-sectional study was carried out by Department of Medical Education UOL and Department of Pediatric Medicine KEMU from February to December 2021. Data about the perception of EE was collected from the Pediatric Medicine trainees by purposive sampling using the 40 items PHEEM inventory. The inventory has three perception domains: role autonomy, teaching, and social support. In addition, to mean scores, the inventory also gives interpretation according to the score ranges. The FCPS and MD trainees of both genders and all years of training across the institutions of Punjab were approached using Google Forms. SPSS (v 23.0) was used for descriptive and analytic statistics. Results: A total of 327 trainees' responses were included-188 (57.5%) FCPS and 139 (42.5%) MD trainees. The mean overall score was 92±19.7 for FCSP and 93.88±21.5 for MD trainees (p-value 0.41). The interpretation of the overall score was "more positive than negative but room for improvement" in 67.3%. For the subscales of role autonomy, teaching, and social support, the perception was positive by 71%, 80%, and 45% of trainees, respectively. Except for three individual items, the mean scores of the subscales and the individual items were not statistically different between the two groups. Conclusion: The Pediatric Medicine trainees' perception of the educational environment in the FCPS and MD groups was comparable overall and in all three domains. Individual item analysis showed almost similar areas for improvement in both programs.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan.

OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

A prospective study on linking diarrheagenic E. coli with stunted childhood growth in relation to gut microbiome.

Stunted growth is an emerging global challenge affecting children under the age of 5 years in low- and middle-income countries. Despite such a high global prevalence of stunting, the mechanism of pathogenesis and the role of associated gut microbiota is poorly understood. The present study was designed to investigate the association of pathogenic strains of E. coli with the residential gut microbiota of stunted growth children. A total of 64 stool sample were collected from children aged ≤ 5 years, and were processed for isolation and molecular characterization of diarrheagenic E. coli. Selected stool samples (n = 39 including three normal controls) were then analysed for microbial community profiling using 16S ribosomal RNA (rRNA) gene sequencing. Furthermore, associations between changes in the microbiota in the presence of different E. coli strains was explored. Pathotyping of the isolated E. coli (n = 64) has shown that 39.68% belonged to one of the five pathotypes of E. coli whilst the remaining ones were non-typeable. Amongst the different pathotypes, EPEC was found to be the most prevalent (52%; n = 13), followed by EAEC (20%; n = 5), EIEC (12%; n = 3), EHEC (8%; n = 2) and ETEC 2 (8%; n = 2). Phylogrouping analysis has shown that majority of the strains belonged to B2 (28.12%). Microbial diversity is shown to be significant and varied when the samples are organized under the recovered phylogroups. Moreover, based on predictive metabolism, the colonization of these strains were found to be significantly associated with energy utilization pathways such as Denovoprine-2 and glyoxylate-by. Differential analysis has shown that Escherichia-Shigella and Enterococcus were altered for the children with stunted growth.

Validity of Pediatric Index of Mortality 2 score as an Outcome Predictor in Pediatric ICU of a Public Sector Tertiary Care Hospital in Pakistan.

Pediatric Index of Mortality 2 (PIM-2) is one of the leading mortality scores used in intensive care units all around the world. We assessed its validity as an outcome predictor in a pediatric intensive care unit (PICU) of Mayo Hospital/King Edward Medical University Lahore, Pakistan. We enrolled 154 consecutive admissions, aged 1 month to 13 years, requiring intensive care from January to June of 2019. Patient demographics along with PIM-2 data were collected; PIM-2 score and mortality risk was calculated; and the outcome recorded as death or survival. The median age at admission was 0.50 years (interquartile range [IQR]: 0.24-1.78) and the median weight was 5.0 kg (IQR: 3.08-10.0) with females constituting 54%; malnutrition was also common (66%). Observed mortality was 29.9% (46 out of 154) and expected mortality (cut-off ≥ 99.8%) was 27.9% with a standardized mortality ratio of 1.07 (95% confidence interval [CI]: 0.79-1.41). Sepsis was the most common diagnosis at admission (27.9%) with the highest mortality (52.2%). Chi-square analysis revealed a sensitivity of 54.3% and a specificity of 83.3% ( p -value 0.00). PIM-2 score showed acceptable discrimination between survivors and nonsurvivors with an area under the receiver operating characteristic curve of 0.75 (95% CI: 0.67-0.84) ( p -value = 0.00); however, poor calibration according to Hosmer-Lemeshow goodness of fit test (Chi-square = 15.80, df = 7, and p -value of 0.027 [< 0.1]), thus requiring recalibration according to local population characteristics.

Impact of COVID-19 pandemic on postgraduate training in Paediatrics.

OBJECTIVE: To assess the impact of the coronavirus disease-2019 pandemic on paediatric postgraduate training as perceived by the trainees. METHODS: The cross-sectional exploratory study was conducted at the Department of Paediatrics, King Edward Medical University, Lahore, Pakistan, from May to June 2020, and comprised paediatric postgraduate trainees associated with various hospitals across the country who were approached online with a pre-designed 24-item questionnaire during the peak months of the pandemic. Data was analysed using SPSS 25. RESULTS: Of the 226 postgraduates, 134(59.2%) were females. The overall mean age was 28.85±3.06 years. Of the total, 200(88.5%) and 195(86.2%) reported that pandemic had adversely impacted their training and research. The number of trainees managing >30 patients and doing >5 procedures per week before the pandemic decreased from 126(55.8%) and 150(66.4%) to 38(16.8%) and 41(18.1%), respectively, during the pandemic (p=0.01). Regarding e-learning, 168(74.3%) trainees thought it might partly compensate for training, 135(59.7%) showed readiness for it, and 179(79.2%) believed this could not replace actual patient interaction. CONCLUSIONS: The coronavirus disease-2019 pandemic was found to have adversely impacted paediatric postgraduate training.

Rasmussen's Encephalitis: A Rare Cause of Intractable Seizures.

Rasmussen's encephalitis (RE) is a rare chronic progressive inflammatory disease of the brain that results in difficult-to-control seizures (mostly focal: epilepsia partialis continua), cognitive decline and progressive loss of neurological function including speech, motor skills with eventual paralysis of one half of the body (hemiparesis) and encephalitis. It is a disease that usually affects a single hemisphere and presents commonly at an early age. It poses a lot of challenges, both in diagnosis as well as treatment. We report a case consistent with the findings of RE in a 4.5-year male child, who presented with status epilepticus; and was diagnosed as a case of RE on clinical and radiological findings. Key Words: Rasmussen's encephalitis, Inflammatory disease, Seizures, Cognitive decline, Hemiparesis.

Impact of COVID-19 on the Children with Cancer in Six Pediatric Oncology Units (POUs) of Pakistan- A Multi-Center Study.

The study is to evaluate the impact of COVID-19 in the Pediatric Oncology Units (POUs) of Pakistan. Data from 1 April 2019 to 30 June 2019 and 1 April 2020 to 30 June 2020 for the first and second cohort, respectively, in order to compare the registration, abandonment rate, and delay in treatment. Six hundred and thirty-four were registered cases, 379 and 255 in the first and second cohort, respectively, which was significantly different <0.005. Seventy-seven were abandoned, 45 and 32 in the first and second cohort, respectively. Fifty-nine COVID-19 positive cases, 24, 4, 27, and 4 were admitted, referred, home isolated, and leave against medical advice (LAMA), respectively. Delayed treatment and reduction in new cases were observed.

Emollient Therapy in Preterm & Low Birth Weight Neonates: A Randomised Clinical Trial.

OBJECTIVE: To assess the impact of emollient therapy on gain in weight and length among preterm and low birth weight babies. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY: Department of Pediatric Medicine, KEMU / Mayo Hospital Lahore, from January till June 2018. METHODOLOGY: Infants with birth weight between 1.5 and 2.5 Kgs or preterm neonates born between 28 and 37 completed weeks of gestation were included in the study. Neonates with genetic syndrome, infection or with a history of admission in NICU due to any reason, were excluded. They were randomly divided into two groups-A and B, by lottery method. Mothers of the neonates in group A were advised massage with sunflower oil; while mothers of the neonates in group B were advised massage without any emollient. Babies were closely followed up and their weight and length were measured at two months of age and were analysed using SPSS version 23.0. RESULTS: For 140 neonates, the mean increase in weight was 489.84 ± 297.48 grams among group-A neonates (emollient therapy group) and it was 373.43 ± 276.31 grams among group-B neonates (p = 0.018). The mean increase in length was 6.5 ± 1.1 cm, among group-A neonates and 4.8 ± 1.3 cm in group-B neonates (p ˂0.001).  Conclusion: Massage with emollient therapy leads to significantly more increase in weight and length compared to massage alone, among preterm and low birth weight neonates. Emollient therapy is an effective non-pharmacological intervention for increasing weight and length in low birth weight and preterm neonates. Key Words:  Emollient, Massage, Low birth weight, Preterm neonates, Weight, Length.

Frequency of need for Mechanical Ventilation and Dialysis in Children with Septic Shock.

To determine the frequency of need for mechanical ventilation and dialysis in children admitted with septic shock to the Paediatric Intensive Care Unit (PICU), this descriptive case series was conducted from August 2015 to February 2016. A total of 100 children from 1 month to 15 years of age of both sexes having septic shock diagnosed within 24 hours of admission were enrolled from the PICU of Children's Hospital Lahore after informed consent from parents of the patients. The standard guideline for the treatment of septic shock was followed. Patients were followed throughout the stay in the hospital to assess the need for mechanical ventilation or the need for dialysis. Arterial blood gases and urea, creatinine were assessed daily or more frequently (if needed) till discharge or death. Of the 100 patients recruited in the study, with a mean age of 2.16±3.26 years, 63 (63 %) were male while 37 (37%) were females. The frequency of need for mechanical ventilation was recorded in 75 (75%) while 22 (22%) required dialysis. We concluded that the frequency of dialysis in children admitted to PICU with septic shock is significantly lower as compared to frequency of mechanical ventilation.

Diagnostic accuracy of cerebrospinal fluid lactate in confirmed cases of acute bacterial meningitis in children.

OBJECTIVE: To determine the diagnostic accuracy of cerebrospinal fluid lactate level in confirmed cases of acute bacterial meningitis in children. METHODS: This cross sectional study was conducted in the Department of Paediatrics, King Edward Medical University/ Mayo Hospital, Lahore from January to December 2018. A total of 250 children, between two months - 12 years of age, of both the genders, with suspected acute bacterial meningitis were included by non-probability consecutive sampling. Each child was subjected to lumbar puncture for biochemistry, cytology, culture, and lactate level. CSF lactate level of 1.1-2.4 mmol/L was taken as normal, and >2.4 mmol/L was taken as cut off for acute bacterial meningitis. All collected data was entered and analyzed in SPSS version 22. A 2 x 2 table was made to calculate diagnostic accuracy, sensitivity, specificity, positive and negative predictive value for CSF Lactate. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of CSF lactate taking CSF culture as gold standard was 100%, 60.61%, 17.27%, 100% and 63.6% respectively, with kappa of 0.19 and p value of 0.000. CONCLUSION: At a cut off value of 2.4 mmol/L, cerebrospinal fluid lactate level has a high diagnostic accuracy for acute bacterial meningitis.

Risk factors for candidaemia in neonates with sepsis in a tertiary care hospital in Pakistan.

OBJECTIVE: To determine the risk factors for candidaemia in babies admitted to a tertiary care hospital with neonatal sepsis. METHODS: This nested case control study was conducted in the Neonatal Unit of the department of Paediatrics, King Edward Medical University/Mayo Hospital, Lahore, from January 2017 to June 2018. A total of 350 neonates having sepsis according to the clinical case definition were enrolled in this study by non-probability convenient sampling. Blood culture for bacteria on first day and for candida on fifth day was sent. Patients were started antimicrobial therapy as per institutional policy on admission. All patients were followed for risk factors for development of candidaemia. Data was analyzed by SPSS 22.0, Odds ratio and logistic regression was used to determine the magnitude of risk factors. RESULTS: Among 350 septic neonates, 36 isolates were positive for Candida spp, constituting 10.2% of candidaemia among septic neonates. Necrotizing enterocolitis was found to be the significantly associated risk factor for development of candidaemia. CONCLUSIONS: Necrotizing enterocolitis was found to be an important risk factor for development of candidaemia among hospitalized septic neonates.

Bubble Nasal Continuous Positive Airway Pressure (bCPAP) versus Control in Neonates with Respiratory Distress.

OBJECTIVE: To compare the effectiveness of bubble continuous positive airway pressure (bCPAP) and oxygen inhalation via nasal cannula in neonates presenting with respiratory distress, using Silverman Anderson Retraction Score (SARS). STUDY DESIGN: Randomised clinical trial. PLACE AND DURATION OF STUDY: Department of Paediatrics, Unit-1, KEMU/Mayo Hospital, Lahore, Pakistan, from April 2017 to June 2018. METHODOLOGY: A total of 120 neonates fulfilling inclusion and exclusion criteria were enrolled and were randomly allocated in two groups: Group A and Group B. In group A, neonates were given bCPAP for respiratory support, while neonates in group B were given nasal oxygen as control group. Neonates in both groups were followed for 48 hours. The effectiveness was determined by the reduction in SARS, up to or less than score 3, at the end of a 48-hour period. Data were collected and analysed by SPSS version 20.0. P-value ≤0.05 was taken as significant. RESULTS: In Group A, effectiveness was found to be 93.3%, and in Group B effectiveness was 71.7% (p = 0.003). Median reduction in SARS from 00 to 48 hours, in group A (bCPAP) was 4 (4 - 5) while in group B (control), it was 3 (2 - 3); statistically significant (p <0.001). CONCLUSION: Bubble CPAP was more effective than nasal oxygen alone, in treatment of respiratory distress among neonates. This study suggested that bCPAP should be used more frequently in NICUs of Pakistan to reduce burden of neonatal morbidity due to respiratory distress. Key Words: Bubble CPAP, Respiratory distress, Neonates, Silverman Anderson Retraction Score.

Educational intervention to improve the knowledge of hand hygiene in pediatric residents and nurses.

OBJECTIVES: To assess the improvement in the knowledge of hand hygiene in Pediatric residents and nurses after theoretical and hands-on educational intervention. METHODS: This study was a questionnaire-based cross-sectional survey carried out in the department of Pediatrics, King Edward Medical University/ Mayo hospital Lahore in two weeks period. Total 41 Pediatrics residents and nurses, participated in the study. Initially a pretest questionnaire was given to each participant, followed by an educational intervention: a day's worth of didactic lectures and practical training of practices for infection control. After two weeks, an identical post-test questionnaire was sent to the participants via email. Data were statistically analyzed through SPSS 22. Z test was applied to see the normality of data while paired t test was applied to compare the pretest score with posttest score. RESULTS: Of 41 participants who attended the workshop, 34 participants responded to post-test giving an overall response rate of 83%. Out of 34, there were 27(80%) doctors and 7(20%) nurses, who participated in workshop. Each item of the questionnaire was analyzed, showing that pretest score for questions related to indication for hand washing, minimum timings required for hand rub, and spread of infection from unclean hands was quite low, as compared to post-test score, indicating statistically significant increment (p value 0.000, 0.001and 0.046 respectively). Mean pre-test score for doctors was 3.22 while for nurses, it was 3.14, whereas post-test score was 4.51 and 4.00 for doctors and nurses respectively. Overall, there was statistically significant increase in knowledge after educational intervention. CONCLUSION: There is statistically significant impact of educational intervention on improving the knowledge of Pediatric residents and nurses with respect to hand hygiene practices.

Spectrum of Joint Deformities in Children with Juvenile Idiopathic Arthritis.

OBJECTIVE: To determine the frequency and types of joint deformities in children with juvenile idiopathic arthritis and their association with clinical parameters and rheumatoid factor. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Rheumatology Outpatient Clinic, the Children's Hospital and the Institute of Child Health, Lahore, from September 2014 to February 2015. METHODOLOGY: All patients of both genders of less than 16 years of age, who fulfilled the International League of Association for Rheumatology (ILAR) criteria for Juvenile Idiopathic Arthritis (JIA), were enrolled in this study. Their demographic data, duration of disease at the time of presentation, types of JIA, various joint deformities and rheumatoid factor (RF) were documented. Statistical analysis of data was done on SPSS version 16. Chi-square test was applied to determine the association of clinical deformity with age of patients, disease duration at presentation, types of JIA and RF. RESULTS: Out of 70 patients enrolled during the study period, 51.4% were boys with mean age at presentation being 9.44 ±3.89 years (2-7 years) and median duration of disease being 24 months (interquartile range 42 months). Forty patients (57.1%) had joint deformities. Most common joints involved were hand (50%), wrist (50%), and knee (35.7%). The common types of joint deformities were boutonniere deformity (28.6%), ulnar deviation of wrist (28.6%), fixed flexion deformity of wrist (22.9%), and knee (31.4%). The most common type of JIA was polyarthritis RF negative with or without deformity. There was a strong association of deformities with older age of patients at presentation (p=0.036), longer duration of disease at presentation (p=0.028), polyarthritis (RF seronegative / seropositive) (p=0.013), and seropositivity (p=0.04). CONCLUSION: More than 50% patients with JIA have joint deformities. Joint deformities are more likely to be seen in children with long-standing disease, those with polyarthritis JIA and seropositive patients.

Knowledge Of Maintenance Intravenous Fluid Therapy In Acutely Ill Hospitalized Children Among Residents.

BACKGROUND: Isotonic saline is recommended as maintenance intravenous fluid therapy (MIVFT) for most of the acutely ill hospitalized children. The aim of this study is to assess the current knowledge of paediatric residents regarding the selection of MIVFT in hospitalized children. METHODS: We conducted a paper-based questionnaire survey to paediatric residents from ten centres asking selection of MIVFT in four common clinical scenarios in 6-month and 10-year old patients as well as monitoring of fluid balance and electrolyte. RESULTS: 445 responses were collected (>90% response rate). Majority [78.3% (n=348)] of them were FCPS-trainees. The 0.9%, 0.45% and 0.2% solution were selected by 45.8%, 43.98% and 10.92% respectively. The isotonic and hypotonic solution was prescribed in 6- mo (35.22% vs. 64.76% [p<0.001]) and 10-year (54.49% vs. 44.98%) in four different clinical scenarios respectively. 0.45% solution was most commonly prescribed MIVFT in pneumonia (50.22%) and meningitis (45.39%) and 0.9% solution was most commonly selected in acute gastroenteritis (55.05%) and post-operative patients (51.23%). Fluid balance and electrolyte monitoring were selected by 96.9% and 55.7% respondents respectively. CONCLUSIONS: Our survey reports that more than fifty percent of paediatric residents have inadequate knowledge about maintenance intravenous fluid therapy in acutely ill hospitalized children.

Touraine-Solente-Gole syndrome in two siblings.

Hypertrophic Osteoarthropathy secondary to various causes is not a common entity but primary hypertrophic osteoarthropathy (also called Touraine-Solente-Gole Syndrome) is an extremely rare genetic disorder. It was first described in 1868 by Friedrich and has premier features of clubbing, periostosis and pachydermia. Based on clinical manifestations Touraine Solente and Gole distinguished it into three forms as complete, incomplete and fruste form. Most of the cases described up till now had onset in late adolescence. This report describes two siblings having symptoms consistent with Touraine-Solente-Gole Syndrome which had onset in early childhood.

Ventilator-associated pneumonia in children.

OBJECTIVE: To determine the frequency of Ventilator-Associated Pneumonia (VAP) and to identify the associated factors, causative organisms and outcome of VAP in children admitted to ICU. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Medical ICU (MICU) of the Children's Hospital and Institute of Child Health, Lahore, from August 2008 to March 2009. METHODOLOGY: All children admitted to MICU and requiring ventilation during the study period were included and monitored for any features suggestive of VAP. Partial septic screen was done in all suspected cases. VAP was labelled when any patient on the ventilator for more than 48 hours had at least 2 of the following features of nosocomial infection - fever > 101°F, TLC < 4000 or > 15000 per mm3, neutrophils > 85%, CRP > 48 mg/L or new findings on chest examination suggestive of pneumonia; and radiological evidence of new or progressive and persistent infiltrates. Percentages were compared using chi-square test with the significance at p-value less than 0.05. RESULTS: Of the 93 children requiring mechanical ventilation during the study period, 16 developed VAP (17%). Almost half (46%) were younger than 1 year with male to female ratio of 1.2:1. Children developing VAP required ventilation for 13.5 (+ 10.1) days compared to 7.7 (+ 5.5) days in those who did not develop VAP. The common organisms isolated were Pseudomonas, Klebsiella and E. coli. Factors associated with increased frequency of VAP included age less than 1 year, unplanned emergency intubation and use of continuous intravenous sedation. Features that strongly suggested underlying VAP included purulent tracheal secretions compared to increased secretions alone, CRP > 48 mg/L, positive radiological findings and positive tracheal aspirate culture. Overall mortality was 23% among the ventilated cohort. Thirty two percent of them had VAP compared to only 13% among those who survived to discharge (p = 0.03). CONCLUSION: The frequency of VAP was 17% in this series. Factors significantly associated with VAP were age less than 1 year, unplanned intubation and continuous sedation. The important predictors of VAP included purulent tracheal secretions, high CRP and persistent new radiological findings.

Predictors of intractable childhood epilepsy.

OBJECTIVE: To determine the prognosis of seizures in epileptic children and identify early predictors of intractable childhood epilepsy. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: The Epilepsy Centre of the Children's Hospital Lahore, from February 2005 to April 2007. PATIENTS AND METHODS: All children (aged 1 month to 16 years) with idiopathic or cryptogenic epilepsy who were treated and followed at the centre during the study period were included. The patients who had marked seizures even after two years of adequate treatment were labeled as intractable epileptics (cases). Children who had no seizure for more than one year at last follow-up visit were the controls. Adequate treatment was described as using at least three anti-epileptic agents either alone or in combination with proper compliance and dosage. Records of these patients were reviewed to identify the variables that may be associated with seizure intractability. RESULTS: Of 442 epileptic children, 325 (74%) intractable and 117 (26%) control epileptics were included in the study. Male gender (OR=3.92), seizures onset in infancy (OR=5.27), = 10 seizures before starting treatment (OR=3.76), myoclonic seizures (OR=1.37), neonatal seizures (OR=3.69), abnormal EEG (OR=7.28) and cryptogenic epilepsy (OR=9.69) and head trauma (OR=4.07) were the factors associated with intractable epilepsy. Seizure onset between 5-7 years of age, idiopathic epilepsy, and absence seizures were associated with favourable prognosis in childhood epilepsy. CONCLUSION: Intractable childhood epilepsy is expected if certain risk factors such as type, age of onset, gender and cause of epilepsy are found. Early referral of such patients to the specialized centres is recommended for prompt and optimal management.

Nosocomial bloodstream infection in a tertiary care paediatric intensive care unit.

OBJECTIVE: To determine the frequency, causative organisms and susceptibility pattern of nosocomial bloodstream infections in children. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Paediatric Intensive Care Unit of the Children's Hospital, Lahore, from January to December 2004. PATIENTS AND METHODS: All children admitted to the unit during the study period were daily evaluated for features suggestive of nosocomial infection. In addition to other investigations, blood cultures were done in all suspected cases for the confirmation of nosocomial bloodstream infection (BSI). Nosocomial infection was defined according to the criteria set by Centre for Disease Control and Prevention. Demographic, microbiological and other variables were carefully studied to analyze frequency, incidence rate, spectrum of isolates and susceptibility pattern. Children with and without nosocomial BSI were compared with regard to age, duration of stay in hospital, need and duration of ventilation and the outcome. RESULTS: Of the total 406 admissions, 134 children were suspected to have nosocomial infection on at least 214 occasions (episodes). Blood cultures yielded growth of pathological organisms in 62 of these episodes, giving the frequency of nosocomial BSI as 15.2 per 100 admissions (62/406 episodes). Children with nosocomial bloodstream infection were found to have younger mean age (2.1 vs. 4.1 years), longer average duration of stay (13.1 vs. 6.6 days), more frequent need for ventilation (64% vs. 34%) and longer duration of ventilation (9.7 vs. 4.8 days). Majority of isolates (77%) were gram-negative bacteria; Klebsiella being the most common isolate (n= 23). Aztreonam, Ceftiazidime, Ceforuxime and Ciprofloxacin showed high resistance pattern (33-50%). Isolates showed good sensitivity to Vancomycin (100%), Imipenem (80%), Meropenem (100%) and Co-amoxiclav (88%). CONCLUSION: The frequency of nosocomial BSI in the observed setting was quite high, having marked impact on the duration of stay and outcome. Emergence of resistant pathogens is alarming.