Distribution and antibiotic sensitivity pattern of Mycobacterium tuberculosis isolates from children, enrolled in a tertiary care hospital.

The present study was planned to assess the distribution of tuberculosis in children and evaluate the antimycobacterial sensitivity pattern of Mycobacterium tuberculosis (MTB) isolates from pediatric patients. A total number of 1718 pediatric patients suspected of Mycobacterium tuberculosis were enrolled in the Institute of Child Health and Children's Hospital, Lahore during 2016-17. Out of 1718, only 710 different types of samples were tested for MTB. The samples were processed using bacteriology and GeneXpert along with the chest X-ray and clinical picture of the patients. The sensitivity pattern of Streptomycin, Isoniazid, Rifampicin and Ethambutol (SIRE) was determined using BACTEC MGIT 960. Total patients were divided into four groups including group A (birth to 12 months), B (1 to 5 years), C (6 to 10 years), and D (11 to 15 years). Out of 710, 106 (55 females and 51 males) were declared positive and 604 negative for tuberculosis. Out of 106 positive cases, 89 (83.96%) were sensitive to Rifampicin and 17 (16.04%) were resistant. Only, 04 (3.77%) were resistant to both Rifampicin and Isoniazid and declared as multidrug-resistant (MDR). It was concluded that children of age 11 to 15 years were more prone to MTB and a minimum percentage of MDR isolates was recorded in age group A (birth to 12 months).

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.

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.

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.

Postgraduate residents' perception of the clinical learning environment; use of postgraduate hospital educational environment measure (PHEEM) in Pakistani context.

OBJECTIVE: To evaluate the perception of postgraduate residents about the clinical educational environment and to investigate the association of their perception with different specialities and years of residency. METHODS: The study was conducted in August 2016 at The Children's Hospital, Lahore, Pakistan, and comprised postgraduate residents who were asked to complete postgraduate hospital educational environment measure questionnaire. The residents' individual perception scores were calculated and the means of both individual domain and global score of the questionnaire were compared by different specialities and different levels of residency training year. SPSS 20 was used for statistical analysis. RESULTS: Of the 160 residents who completed the questionnaire, 114(71.3%) were related to paediatric medicine. The residents perceived their educational environment positive with a global mean score of 88.16±14.18. Autonomy and teaching were rated most highly by paediatric diagnostic residents, i.e. 32.23±8.148 and 36.23±9.010, respectively. Social support was rated the highest by paediatric surgery residents 24.36±4.653. There was no significant difference of perception between different specialities (p=0.876) or different years of residency (p=0.474). CONCLUSIONS: Postgraduate hospital educational environment measure can be used to identify areas of strengths and weaknesses in a hospital environment. Educational environment of study site was more positive than negative.

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.

Phenotypic characterization of extended-spectrum-beta-lactamase producing E. coli from healthy individuals, patients, sewage sludge, cattle, chickens and raw meat.

OBJECTIVE: The present study aimed to determine the frequency and antimicrobial profile of ESBL-producing isolates of E. coli in different environments. METHODS: This cross-sectional study was conducted at The Children's Hospital and The Institute of Child Health, Lahore from July to December 2015. The faecal specimens from healthy individuals, patients, sewage sludge, cattle, chickens and raw meat (n = 122) were processed for microbiological analysis using MacConkey agar supplemented with cefotaxime. The identification of organisms was confirmed by API 10S and antimicrobial resistance profile was recorded by Kirby-Bauer disc diffusion method. RESULTS: On the basis of screening, 77 (63.0%) specimens were found to be positive for ESBL production. The confirmation of 74 (60.0%) ESBL producing E. coli was done using double disc synergy test (DDST). The frequency of ESBL producing E. coli was found to be 17 (57.0%) in healthy individuals, 15 (53.0%) in patients, 10 (66.0%) in cattle faeces, 5 (71.0%) in sewage sludge, 14 (70.0%) in raw meat and 13 (59.0%) in chicken faeces. All of these isolates were resistant to cephalosporins and some of these were resistant to fluoroquinolones and meropenem. None of the isolates showed resistance to cefoperazone-sulbactam, imipenem, piperacillin-tazobactam and amikacin. CONCLUSION: The prevalence of ESBL-producing E. coli was recorded in all the environments, suggesting a global expansion of these enzymes.

Acute bacterial meningitis in children presenting to The Children's Hospital Lahore before and after pneumococcal vaccine in Pakistan National Immunization Program; A comparison.

OBJECTIVE: To describe bacteriological profile, morbidity and mortality of acute bacterial meningitis (ABM) in children and to compare these parameters before and after the introduction of Pneumococcal vaccine in Pakistan National Immunization Program. METHODS: The present descriptive study was conducted at the Department of Paediatric Medicine of The Children's Hospital Lahore from January 2012 to December 2015. A total of 503 children one month to five years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry, culture sensitivity and blood culture sensitivity were performed. RESULTS: Frequency of meningitis decreased by 50% in 2013-2015 (199 [2012] vs 304 [2013-2015). Most children in both groups were under one year of age. More neurological complications were seen in the group 2, 20% vs 17%. CSF culture positivity decreased from 12% to 6.6%. Streptococcus pneumoniae isolation decreased from 5 (2.5%) in 2012 to 4 (1.3%) in 2013-2015. Refusal to take feed (p=0.002), impaired sensorium (p=<0.001), severe malnutrition (p=0.001), prolonged duration of symptoms (p=<0.001) and incomplete vaccination status (0.005) were associated with mortality. Mortality rate decreased from 20 (10%) in 2012 to 17 (5.6%) in 2013-2015 but more children developed neurological sequelae 2.7% versus 1%. CONCLUSION: Acute bacterial meningitis mostly affected children <1 year. Frequency of Streptococcus pneumoniae and mortality of meningitis decreased significantly after PCV but more neurological complications developed in those children who were unvaccinated in 2013-2015 compared to 2012.

Correlation between maternal and childhood VitB12, folic acid and ferritin levels.

OBJECTIVE: To determine the correlation between serum folic acid, vitamin B12 and ferritin of mother and child and to study various neonatal risk factors as a cause of anemia in children. METHODS: One hundred eighty children two months to two years of age admitted in the department of Pediatric Medicine of The Children's Hospital and The Institute of Child Health Lahore from January 2013 to January 2015 with common medical conditions having anemia were included. Complete blood count (CBC), serum ferritin level, folic acid and Vitamin (Vit) B12 level were sent of children and their mothers. Data was analyzed using SPSS version 20. RESULTS: Out of 180 children with anemia, 66.7% were males. Mean age of children was 7.3months. Fifty-five percent children were malnourished according to z scoring. The mean Hemoglobin (Hb) of children was 8 g/dl. Only 4% children had low ferritin level while 60% had low folic acid and 45% had decreased VitB12. There was significant correlation between Hb of mother and child (p =0.02), Vit B12 deficiency (p=0.008) and iron deficiency (p<0.001). Premature children had lower folic acid levels (p =0.02), while prematurity, IUGR, previous admission and history of sepsis showed no association with anemia in our study. Both breast-feeding and top feeding showed significant association with anemia with p-value of 0.042 and 0.003 respectively while dilution showed no impact on anemia. CONCLUSION: Maternal anemia has a significant impact on child's hemoglobin. As compared to previous concept of increased iron deficiency in children we found increased occurrence of folic acid and VitB12 deficiency in children and their mothers.

Analyzing communication skills of Pediatric Postgraduate Residents in Clinical Encounter by using video recordings.

OBJECTIVE: To analyze communication skills of pediatric postgraduate residents in clinical encounter by using video recordings. METHODS: This qualitative exploratory research was conducted through video recording at The Children's Hospital Lahore, Pakistan. Residents who had attended the mandatory communication skills workshop offered by CPSP were included. The video recording of clinical encounter was done by a trained audiovisual person while the resident was interacting with the patient in the clinical encounter. Data was analyzed by thematic analysis. RESULTS: Initially on open coding 36 codes emerged and then through axial and selective coding these were condensed to 17 subthemes. Out of these four main themes emerged: (1) Courteous and polite attitude, (2) Marginal nonverbal communication skills, (3) Power game/Ignoring child participation and (4) Patient as medical object/Instrumental behaviour. All residents treated the patient as a medical object to reach a right diagnosis and ignored them as a human being. There was dominant role of doctors and marginal nonverbal communication skills were displayed by the residents in the form of lack of social touch, and appropriate eye contact due to documenting notes. A brief non-medical interaction for rapport building at the beginning of interaction was missing and there was lack of child involvement. CONCLUSION: Paediatric postgraduate residents were polite while communicating with parents and child but lacking in good nonverbal communication skills. Communication pattern in our study was mostly one-way showing doctor's instrumental behaviour and ignoring the child participation.

Childhood Acute Bacterial Meningitis: Clinical Spectrum, Bacteriological Profile and Outcome.

OBJECTIVE: To determine the disease pattern, etiological agents and outcome of childhood acute bacterial meningitis. STUDY DESIGN: Adescriptive study. PLACE AND DURATION OF STUDY: Department of Paediatric Medicine, The Children's Hospital, Lahore, from January to December 2012. METHODOLOGY: Atotal of 199 children between the ages of 1 month and 5 years, admitted with the diagnosis of meningitis on the basis of clinical findings and positive cerebrospinal fluid (CSF), were included. In all patients, complete blood count (CBC), CSF culture sensitivity, and blood culture sensitivity were performed. Data was analysed using SPSS version 20. RESULTS: Out of 199 children, 127 (63.8%) were males with M:F ratio of 1.7:1. Mean age was 11.33 ±12 months. Maximum numbers of children were < 1 year of age, 136 (68.3%). Only 90 (45.2%) children were fully vaccinated according to Expanded Program of Immunisation (EPI) schedule. Presentations with refusal to take feed (p=0.008) and with impaired conscious state were independent predictors of death (p=0.002). Complications were noted in 34 (17%) and were significantly associated with severe malnutrition (p=0.006) and altered conscious level at presentation (p < 0.001). The common pathogens identified on CSF culture were coagulase negative staphylococci (CoNS) in 11 (5.5%) and streptococcus pneumoniaein 5 (2.5%). Overall mortality was 10.1%. The commonest pathogen isolated from children who died was streptococcus pneumoniae(p=0.039). CONCLUSION: Acute bacterial meningitis mostly affected children under the age of 1 year. CSF culture revealed both Grampositive and Gram-negative bacteria. The most common pathogen in children who died was streptococcus pneumoniae.

Metallo-beta-lactamase producing Escherichia coli and Klebsiella pneumoniae: A rising threat for hospitalized children.

OBJECTIVE: To determine the frequency of metallo-beta-lactamase (MBL) producing E.coli and Klebsiella pneumoniae, better phenotypic techniques for MBL detection and choices of treatment available for such cases. METHODS: This study was conducted in The Children's Hospital, Lahore during March, 2013 and February, 2014. A total number of 17,651 samples including blood, urine, CSF, pus and catheter tips from suspected cases of bacterial infections were processed and test organisms were identified using standardized microbiological techniques. MBL phenotypic identification was performed by Modified Hodge Test, Double Disc Synergy Test and Combined Disc Test. RESULTS: Carbapenem resistance was observed in 134/1168 (11.47%) strains which comprised of 89 (67.4%) Klebsiella pneumoniae and 45 (32.6%) E.coli. All of these carbapenem resistant isolates were found to be carbapenemase producers (CP) by MHT test. Among these CP strains, MBL was detected in 131/134 (97.8%) isolates both by CDT and DDST including 87 (66.4%) Klebsiella pneumoniae and 44 (33.6%) E.coli. Majority of these organisms were resistant to most of the antibiotics used in the study. The isolates showed good susceptibility to colistin (90.1%), chloramphenicol (60.3%) and fosfomycin(31%). CONCLUSIONS: Isolation of such a high number of MBL producers is a serious threat for hospitalized paediatric patients.

Medical errors; causes, consequences, emotional response and resulting behavioral change.

OBJECTIVE: To determine the causes of medical errors, the emotional and behavioral response of pediatric medicine residents to their medical errors and to determine their behavior change affecting their future training. METHODS: One hundred thirty postgraduate residents were included in the study. Residents were asked to complete questionnaire about their errors and responses to their errors in three domains: emotional response, learning behavior and disclosure of the error. The names of the participants were kept confidential. Data was analyzed using SPSS version 20. RESULTS: A total of 130 residents were included. Majority 128(98.5%) of these described some form of error. Serious errors that occurred were 24(19%), 63(48%) minor, 24(19%) near misses,2(2%) never encountered an error and 17(12%) did not mention type of error but mentioned causes and consequences. Only 73(57%) residents disclosed medical errors to their senior physician but disclosure to patient's family was negligible 15(11%). Fatigue due to long duty hours 85(65%), inadequate experience 66(52%), inadequate supervision 58(48%) and complex case 58(45%) were common causes of medical errors. Negative emotions were common and were significantly associated with lack of knowledge (p=0.001), missing warning signs (p=<0.001), not seeking advice (p=0.003) and procedural complications (p=0.001). Medical errors had significant impact on resident's behavior; 119(93%) residents became more careful, increased advice seeking from seniors 109(86%) and 109(86%) started paying more attention to details. Intrinsic causes of errors were significantly associated with increased information seeking behavior and vigilance (p=0.003) and (p=0.01) respectively. CONCLUSION: Medical errors committed by residents have inadequate disclosure to senior physicians and result in negative emotions but there was positive change in their behavior, which resulted in improvement in their future training and patient care.

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.