Clinical pattern, neuroimaging findings and outcome of Acute Disseminated Encephalomyelitis in children: A retrospective study.

Objective: To determine the clinical spectrum, neuroimaging findings, and outcome of Acute Disseminated Encephalomyelitis (ADEM) in children. Method: We conducted a descriptive cross sectional study of all children aged 6 months to 18 years, diagnosed with ADEM at Aga Khan University Hospital, Karachi from January 2018 till December 2022. Results: This retrospective study enrolled 30 cases of ADEM, with a mean age of 6.43 ± 4.079, including 13 males and 17 females. The average hospital stay was 7.29 ± 4.379 days. The most common clinical features were fever, headache, and altered consciousness, while motor deficit was observed in 15 (53.5%) patients. Abnormal cerebrospinal fluid was found in 14 (46.6%) patients. Brain MRI identified bilateral and multifocal lesions in 22 (78.6%) patients, with brainstem lesions detected in 7 (25%) patients. Treatment included IV methylprednisolone (22; 73%), IVIG (9; 30%), or both (6; 20%). Clinical improvement was observed in 25 (89.3%) patients, with residual weakness present in eight (26%) patients at discharge. There was one reported death. Long-term complications included motor deficits, seizures, poor scholastic performance, and behavioral issues. Conclusion: The clinical presentation of ADEM is variable, but the most common symptoms are fever, headache, and altered consciousness. Despite generally favorable outcome, long-term monitoring revealed that patients may experience motor deficits, seizures, cognitive impairment, and academic difficulties.

Biomarker-Based Risk Stratification in Pediatric Sepsis From a Low-Middle Income Country.

OBJECTIVES: Most biomarker studies of sepsis originate from high-income countries, whereas mortality risk is higher in low- and middle-income countries. The second version of the Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) has been validated in multiple North American PICUs for prognosis. Given differences in epidemiology, we assessed the performance of PERSEVERE-II in septic children from Pakistan, a low-middle income country. Due to uncertainty regarding how well PERSEVERE-II would perform, we also assessed the utility of other select biomarkers reflecting endotheliopathy, coagulopathy, and lung injury. DESIGN: Prospective cohort study. SETTING: PICU in Aga Khan University Hospital in Karachi, Pakistan. PATIENTS: Children (< 18 yr old) meeting pediatric modifications of adult Sepsis-3 criteria between November 2020 and February 2022 were eligible. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma was collected within 24 hours of admission and biomarkers quantified. The area under the receiver operating characteristic curve for PERSEVERE-II to discriminate 28-day mortality was determined. Additional biomarkers were compared between survivors and nonsurvivors and between subjects with and without acute respiratory distress syndrome. In 86 subjects (20 nonsurvivors, 23%), PERSEVERE-II discriminated mortality (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.72-0.94) and stratified the cohort into low-, medium-, and high-risk of mortality. Biomarkers reflecting endotheliopathy (angiopoietin 2, intracellular adhesion molecule 1) increased across worsening risk strata. Angiopoietin 2, soluble thrombomodulin, and plasminogen activator inhibitor 1 were higher in nonsurvivors, and soluble receptor for advanced glycation end-products and surfactant protein D were higher in children meeting acute respiratory distress syndrome criteria. CONCLUSIONS: PERSEVERE-II performs well in septic children from Aga Khan University Hospital, representing the first validation of PERSEVERE-II in a low-middle income country. Patients possessed a biomarker profile comparable to that of sepsis from high-income countries, suggesting that biomarker-based enrichment strategies may be effective in this setting.

Characterization and Outcomes of Hospitalized Children With Coronavirus Disease 2019: A Report From a Multicenter, Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) Registry.

OBJECTIVES: Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry. DESIGN: Retrospective study. SETTING: Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry. PATIENTS: Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25-14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16-25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2-7.7 d) and 4 days (1.9-7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased. CONCLUSIONS: In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.

Gastrointestinal Complications in Critically Ill Children: Experience from A Resource-Limited Country.

OBJECTIVES: To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children. METHODS: This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated. RESULTS: GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes. CONCLUSION: GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors.

Burden of Respiratory Disease in Pediatric Intensive Care Unit: Experience from a PICU of a Tertiary Care Center in Pakistan.

Introduction: We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification. Methods: A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi-square test or Fischer's exact test as appropriate. Results: 279 (63.8% male; median age 9 months, IQR 4-36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2-5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024-1.358, P=0.022) and a positive blood culture (OR 4.305; 95% CI 1.062-17.448, P=0.041). Conclusion: Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study.

Creation of Virtual Patients for Undergraduate and Postgraduate Medical Education: An Experience from Pakistan.

OBJECTIVE: To create virtual patients as an educational tool to determine their feasibility and effectiveness in clinical problem solving. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: The Aga Khan University Hospital, Karachi, from 2018 to 2021. METHODOLOGY: Prototype virtual patients were developed at the Aga Khan University Hospital, Karachi, for medical trainees. Articulate Storyline 360 software was used for creating clinical encounters. Undergraduate students and postgraduate trainees were selected using purposive sampling to practice on these virtual patients (VPs). They were asked to provide feedback on the construction and usefulness of virtual patients as a learning modality. RESULTS: Two VPs were created and used. The geriatric VP was used for the assessment of final-year students. Twenty-five students gave detailed feedback after completion. Most (90%) agreed that the VP provided realistic scenarios and improved clinical reasoning. Almost five identified the need to improve navigational instructions. The pediatric VP for postgraduate trainees was well received. Almost 90% reported that it facilitated learning and improved knowledge and clinical reasoning. There was a 30% increase in post-test scores, supporting it as an adjunct resource for clinical learning. CONCLUSION: Virtual patients can be easily created using local disease patterns to make learning more contextual. They enhance clinical reasoning and decision-making in a safe learning environment.   Key Words: Medical education, Virtual patients, e-learning.

Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country.

BACKGROUND: Arrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan. METHODS: A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. RESULTS: Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. CONCLUSIONS: More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia.

Parenting practices, stressors and parental concerns during COVID-19 in Pakistan.

BACKGROUND: COVID-19 is a global crisis that has added fear, uncertainty, and stress to parents. Parents are going through several challenges related to school closure, financial insecurity and working remotely. These stressors are affecting the mental health of parents. OBJECTIVES: This study aimed to observe major stressors along with the impact of COVID-19 on parental concerns and practices during lockdown. PARTICIPANTS: Sample (N = 923) was selected through purposive sampling from parents attending Out Patients Departments of hospitals in three provincial capital cities of Pakistan having a high burden of COVID-19, i.e. Lahore, Karachi and Peshawar. Parents having at least one child younger than 18 years were included in the study. METHODS: A quantitative design was used using a COVID-19 Parenting Response Scale (α = 0.74). It was used as a self-administered tool for parents who knew how to read and write Urdu/English language, however it was conducted as a structured interview for those who could not read/write. Data was analyzed by applying descriptive statistics (frequency, mean, percentage), independent sample t-test and Pearson Product Moment Correlation. RESULTS: Findings of the current study showed several stressful factors for parents during COVID-19 pandemic, mainly financial burden, children's education, uncertainty of the situation, and many others. The study also suggests an association of parental concerns during COVID-19 with parenting practices. CONCLUSION: COVID-19 pandemic presents a global crisis not only of the health of the people but also on family relations and mental well-being. Findings of this research indicate the need for targeted and accessible interventions for mental health of parents especially during these challenging circumstances so that they can cope with the challenges in an effective way and be able to take care of their children better.

Effectiveness of interventions to screen and manage infections during pregnancy on reducing stillbirths: a review.

BACKGROUND: Infection is a well acknowledged cause of stillbirths and may account for about half of all perinatal deaths today, especially in developing countries. This review presents the impact of interventions targeting various important infections during pregnancy on stillbirth or perinatal mortality. METHODS: We undertook a systematic review including all relevant literature on interventions dealing with infections during pregnancy for assessment of effects on stillbirths or perinatal mortality. The quality of the evidence was assessed using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach by Child Health Epidemiology Reference Group (CHERG). For the outcome of interest, namely stillbirth, we applied the rules developed by CHERG to recommend a final estimate for reduction in stillbirth for input to the Lives Saved Tool (LiST) model. RESULTS: A total of 25 studies were included in the review. A random-effects meta-analysis of observational studies of detection and treatment of syphilis during pregnancy showed a significant 80% reduction in stillbirths [Relative risk (RR) = 0.20; 95% confidence interval (CI): 0.12 - 0.34) that is recommended for inclusion in the LiST model. Our meta-analysis showed the malaria prevention interventions i.e. intermittent preventive treatment (IPTp) and insecticide-treated mosquito nets (ITNs) can reduce stillbirths by 22%, however results were not statistically significant (RR = 0.78; 95% CI: 0.59 - 1.03). For human immunodeficiency virus infection, a pooled analysis of 6 randomized controlled trials (RCTs) failed to show a statistically significant reduction in stillbirth with the use of antiretroviral in pregnancy compared to placebo (RR = 0.93; 95% CI: 0.45 - 1.92). Similarly, pooled analysis combining four studies for the treatment of bacterial vaginosis (3 for oral and 1 for vaginal antibiotic) failed to yield a significant impact on perinatal mortality (OR = 0.88; 95% CI: 0.50 - 1.55). CONCLUSIONS: The clearest evidence of impact in stillbirth reduction was found for adequate prevention and treatment of syphilis infection and possibly malaria. At present, large gaps exist in the growing list of stillbirth risk factors, especially those that are infection related. Potential causes of stillbirths including HIV and TORCH infections need to be investigated further to help establish the role of prevention/treatment and its subsequent impact on stillbirth reduction.

Depression and its associated risk factors in medical and surgical post graduate trainees at a teaching hospital: a cross sectional survey from a developing country.

OBJECTIVES: To determine the frequency of depression among post graduate medical trainees in a teaching hospital of Pakistan and to explore the associated factors contributing to depression in them. METHODS: It's a cross-sectional study at the Aga Khan University Hospital, Karachi. It was done in June 2008 till August 2008. Zung Self-Rating Depression Scale was administered among 172 post graduate trainees. Self administered questionnaires were used to assess the associated demographic and work related risk factors. Adjusted odds ratios (OR) were calculated by logistic regression. RESULTS: The survey response rate was 172 (82.69%). Depression in the overall sample was 103 (59.88%), of which 58 (33.66%) were moderate to markedly depressed. Multiple logistic regression analysis revealed that working hours less than 76 hours (OR 3.71; CI = 1.67, 8.23) and 76-90 hours (OR 3.15; CI = 1.42, 6.97) and none or occasional peer support (OR 2.05; CI = 1.01, 4.18) were independent predictors for depression among the post graduate trainees. CONCLUSION: More than half of our sample population was depressed. Therefore, they should be encouraged to recognize and seek treatment. This study also indicates that less working hours and lack of peer support cause depression.

Abstract to publication conversion in pediatric critical care medicine in Pakistan.

BACKGROUND: To determine the rate of conversion of abstracts presented at conferences into full-text articles published in peer-reviewed journals in the field of pediatric critical care medicine (PCCM) in a developing country. METHODS: We retrospectively reviewed PCCM abstracts from Pakistan presented at national and international pediatric and critical care conferences over 10 years (January 2010 to March 2020). Data included abstract characteristics, such as presentation (poster/oral), presenter (fellow/resident), time of meeting (month and year), type of meeting, study design and topic; and publication characteristics, such as journal name, time (month and year) and first author. The primary outcome was publication rate of PCCM abstracts presented in meetings and time (months) from presentation to publication. RESULTS: A total of 79 PCCM abstracts were presented in 20 meetings during the study period. There were 65 poster presentations (82.28%), of which 63 (79.74%) were presented at international critical care conferences and all presenters were PCCM fellows. In total, 64 (81%) abstracts were descriptive observational studies (retrospective: 50, 63.29%) and prospective (14, 17.72%). Only one was an interventional randomized controlled trial. The publication rate of PCCM abstracts was 63.3% (50/79) and the mean time to publication was 12.39±13.61 months. The publication rate was significantly correlated to the year of publication (P<0.001). CONCLUSIONS: The PCCM abstract publication rate and mean time from presentation to publication was 63.3% and 12.39±13.61 months, respectively, in a developing country.

Clinical profile and treatment of infantile spasms using vigabatrin and ACTH--a developing country perspective.

BACKGROUND: Infantile spasms represent a serious epileptic syndrome that occurs in the early infantile age. ACTH and Vigabatrin are actively investigated drugs in its treatment. This study describes the comparison of their efficacy in a large series of patients with infantile spasms from Pakistan. METHODS: All patients with infantile spasms who presented to Aga Khan University Hospital, Karachi, Pakistan from January, 2006 to April, 2008 were included in this study. Inclusion criteria were clinical symptoms of infantile spasms, hypsarrythmia or modified hyparrythmia on electroencephalography, at least six months of follow-up period and receipt of any of the two drugs mentioned above. The type of drug distribution was random according to the availability, cost and ease of administration. RESULTS: Fifty six cases fulfilled the inclusion criteria. 62.5% were males. Mean age at onset of seizures was 5 +/- 1.4 months. Fifty two (92.8%) patients demonstrated hypsarrythmia on electroencephalography. 64.3% cases were identified as symptomatic while 19.6% were cryptogenic and 16.1% were idiopathic. Eighteen patients received ACTH while 38 patients received Vigabatrin as first line therapy. Initial response to first line therapy was similar (50% for ACTH and 55.3% for Vigabatrin). Overall, the symptomatic and idiopathic groups responded better to Vigabatrin. The relapse rate was higher for ACTH as compared to Vigabatrin (55.5% vs. 33.3%) when considering the first line therapy. Four patients evolved to Lennox-Gastaut variant; all of these patients had initially received Vigabatrin and then ACTH. CONCLUSION: Vigabatrin and ACTH showed no significant difference in the initial treatment of infantile spasms. However, patients receiving ACTH were 1.2 times more likely to relapse as compared to the patients receiving Vigabatrin when considering monotherapy. We suggest that Vigabatrin should be the initial drug of choice in patients presenting with infantile spasms. However, larger studies from developing countries are required to validate the therapeutic trends observed in this study.

Knowledge, attitudes and practices of medical students regarding needle stick injuries.

OBJECTIVE: To ascertain knowledge, attitude and practices of medical students regarding needle stick injuries. METHODS: A cross sectional survey was conducted among the consenting medical students of 3rd, 4th and 5th years at a teaching hospital of Karachi, Pakistan. Convenience sampling was used. Pre-tested questionnaires were administered to approximately 70% of each class. Data was analyzed using SPSS version 16.0. Associations were assessed using chi-square test and Fisher's exact test. A p-value of <0.05 was considered as significant. RESULTS: The response rate of the survey was 85.7%. Sixty one students (33.9%) were from 3rd and 4th year each while 58 students (32.2%) were from 5th year. More than 85% students from each class were aware of the possibility of acquisition of Hepatitis B, Hepatitis C and HIV from needle stick injuries. Only 16.4% 3rd year students, 29.5% 4th year students and 36.2% final year students knew the full details of needle stick injury prevention protocols. Curriculum was cited as an important source of information regarding needle stick injuries. Forty seven (26.1%) students had received a needle stick injury in the past; however, only 14 students (29.7%) had reported the incident either to their consultant or the Infection Control Office. CONCLUSION: Overall knowledge of medical students regarding various aspects of needle stick injuries improved with seniority in medical college. However, the domains of attitude and practices need to be improved as the frequency of needle stick injuries was also observed to increase with the increasing year of medical education.

Breaking bad news: exploring patient's perspective and expectations.

OBJECTIVE: To explore patient's perspectives and expectations from physicians with respect to breaking of bad news. METHODS: A cross-sectional survey was carried out in the Community Health Centre of a tertiary care teaching hospital in Pakistan. All consenting individuals from 18 to 60 years of age were interviewed on the basis of a structured, pre-tested questionnaire. RESULTS: The response rate for this study was 91.3%. A total of 400 respondents completed the full interview. About 60% patients had a fairly accurate idea about the implications of the phrase "bad news". A big proportion (44.1%) of people reported that bad news had been broken to them previously with incomplete details. From their personal experience, most respondents quoted "disease diagnosis" and "chances of survival" as most commonly encountered bad news. Diagnosis of cancer or its recurrence was stated as the most likely example of bad news (35.5%). A significant majority of respondents (40.5%) stated that it's the patient's absolute right to know bad news. A significant association for the relationship between both age as well as the gender of the respondents and type of emotional response expressed on hearing bad news (p = 0.000) was observed. CONCLUSION: This study documents the perceptions and expectations of patients from their physicians with regards to breaking of bad news. Most of the respondents wanted their doctors to be honest and upfront during the process.

Elective Tracheostomy in Critically Ill Children: A 10-Year Single-Center Experience From a Lower-Middle Income Country.

Objective Tracheostomy is a commonly performed procedure amongst critically ill patients, especially in cases of prolonged mechanical ventilation (PMV). This study aimed to describe the indications, clinical characteristics, and outcomes of elective pediatric tracheostomies in critically ill children at our center. Methods A retrospective review of medical records of children who underwent elective tracheostomies in our pediatric intensive care unit (PICU) was conducted from January 2009 to June 2018. Data were extracted based on demographics, indications of tracheostomy, and patient outcomes. Results were reported as mean with standard deviation and as frequencies with percentage. Results Of the 3,200 patients admitted to the PICU during the study period, 1,130 were intubated. A total of 48 (4.2% of 1,130) children underwent an elective tracheostomy. 30/48 (62.5%) children had an early tracheostomy. 34/48 (71%) patients were males. Approximately 25% of our patients undergoing a tracheostomy had an underlying neurological condition as the primary diagnosis, followed by respiratory conditions (23%). The most common indications for elective tracheostomy were PMV (>7 days) (n=24, 50%) and extubation failure (n=9, 18.7%). Early tracheostomy (<14 days) had better patient outcomes in terms of ventilator-free days (8.57±4.64 in early tracheostomy vs. 6.38±6.17 days in late tracheostomy, P=0.04). The sedation-free days and ICU-free days were also significantly increased in the early tracheostomy group than in the late tracheostomy group. The successful weaning and ICU discharge rate were significantly higher in the early tracheostomy group than in the late tracheostomy group (78.1% vs. 59.7%, P<0.05; and 69.2% vs. 49.5%, P<0.05, respectively). Ventilator-associated pneumonia was more common in the late tracheostomy group (n= 14, 77%), compared to early tracheostomy group (n=12, 40%) (P=0.03). Two patients expired from tracheostomy-related complications. Conclusion PMV was the most common indication for an elective tracheostomy. Early tracheostomy is associated with improved patient outcomes; therefore, a standardized approach toward mechanically ventilated children is recommended.

Knowledge, attitudes and practices survey on organ donation among a selected adult population of Pakistan.

BACKGROUND: To determine the knowledge, attitudes and practices regarding organ donation in a selected adult population in Pakistan. METHODS: Convenience sampling was used to generate a sample of 440; 408 interviews were successfully completed and used for analysis. Data collection was carried out via a face to face interview based on a pre-tested questionnaire in selected public areas of Karachi, Pakistan. Data was analyzed using SPSS v.15 and associations were tested using the Pearson's Chi square test. Multiple logistic regression was used to find independent predictors of knowledge status and motivation of organ donation. RESULTS: Knowledge about organ donation was significantly associated with education (p = 0.000) and socioeconomic status (p = 0.038). 70/198 (35.3%) people expressed a high motivation to donate. Allowance of organ donation in religion was significantly associated with the motivation to donate (p = 0.000). Multiple logistic regression analysis revealed that higher level of education and higher socioeconomic status were significant (p < 0.05) independent predictors of knowledge status of organ donation. For motivation, multiple logistic regression revealed that higher socioeconomic status, adequate knowledge score and belief that organ donation is allowed in religion were significant (p < 0.05) independent predictors. Television emerged as the major source of information. Only 3.5% had themselves donated an organ; with only one person being an actual kidney donor. CONCLUSION: Better knowledge may ultimately translate into the act of donation. Effective measures should be taken to educate people with relevant information with the involvement of media, doctors and religious scholars.

Knowledge, attitudes and practices regarding gemstone therapeutics in a selected adult population in Pakistan.

BACKGROUND: Gemstones have been in use as part of alternative and complementary medicine for years. However, our understanding of the perceived healing powers of gemstones is limited. An extensive literature search revealed that there is a dearth of validated information on this subject. This study was therefore undertaken to explore the various aspects of the knowledge, attitudes, and practices of the public towards gemstone therapeutics. METHODS: A survey was performed in the Community Health Centre of a tertiary care teaching hospital in Pakistan. Data collection was done via a face-to-face interview based on a structured, pre-tested questionnaire. Participants included all willing persons between 18-75 years of age approached prior to their appointments at the Community Health Centre. RESULTS: The survey response rate was 86% (400/465). More than half (63%) of the study population was aware of the use of gemstone therapy. One hundred fifty-six individuals believed that gemstone use impacts health. Of this group, 39% believed that gemstone use increases physical strength. 62% believed that gemstone use is based on superstitious beliefs, whereas 28% opined that it is based on religious beliefs. 38% had used gemstones therapeutics formerly, while 24% were current users. Multiple logistic regression analysis revealed that age status and education status were significant (p < 0.05) independent predictors for both awareness of gemstone therapy and the belief that gemstone use impacts health. The elderly (aged 51-61) were 5.9-times more likely to believe that gemstones had an impact on health than the younger population (aged 18-28 years). (Adjusted Odd's Ratio = 5.9 [95% Confidence Interval = 2.9-11.9]). CONCLUSION: More than half of our sample population is aware of the use of the gemstones for their various effects. Willingness to use gemstones is associated with the beliefs about the impact of gemstone therapy on health. Friends and family seem to be the major role players influencing people's willingness to use gemstones. CAM modalities should be recognized and considered as an important therapeutic option. We feel that gemstone therapy is a relatively unexplored area and more studies should, therefore, be conducted to gather more validated information on the subject.

Brown-Vialetto-Van Laere syndrome: a novel diagnosis to a common presentation.

Brown-Vialetto-Van Laere syndrome (BVVLS) or riboflavin transporter deficiency (OMIM 211530) is a rare treatable autosomal recessive neurodegenerative disorder. This condition is associated with progressive pontobulbar palsy. We describe the clinical course of a 16-month-old boy with BVVLS and a novel homozygous mutation from Pakistan. Our patient presented with stridor and respiratory insufficiency. Hearing loss which is the most common sign of this condition was absent, making it an unusual presentation of BVVLS. His examination revealed ptosis and tongue fasciculation. His riboflavin receptor mutational analysis showed the homozygous mutation in the SLC52A3 gene. Per oral riboflavin was administered, and subsequently, he was able to be weaned off the ventilator. Now the child is improving and attaining developmental milestones.

Thrombolysis Using Tissue Plasminogen Activator: Experience from a Critical Care Setting.

To describe the experience of thrombolysis using tissue plasminogen activator (tPA) in critically ill children admitted to the pediatric intensive care unit (PICU), retrospective review of medical records of all children (1 month-16 years), who were admitted in PICU since January 2014 to December 2017 and received systemic tPA for thrombolysis was done. Data was collected on a structured proforma and included thrombus location, tPA dose and duration, outcome (resolution, survival) and complications (bleeding). Total 9 patients (7 males, 2 females) received systemic tPA therapy for thrombolysis with mean age of 74.64 ± 69.58 months. Two patients had thrombus in femoral artery, 3 in IVC and 4 had intra-cardiac thrombosis. Median number of doses was 2 with a range of 1-5 doses. Complete resolution of the clot was noted in all except one patient. A standard starting dose of 0.01 mg/kg/h was used in all patients. Only one patient developed melena after TPA therapy which self-resolved. Systemic tPA therapy was very safe in pediatric critically ill patients and was effective for thrombolysis and did not show any adverse effects in children with varying underlying diagnosis.

Acute Necrotizing Encephalopathy of Childhood Secondary to Dengue Infection: A Case Report from Pakistan.

Acute necrotizing encephalopathy of childhood (ANEC) is a rare condition mainly affecting children with a distinct clinico-radiologic pattern. Initially thought to be secondary to respiratory viral infections, there have been more insights to the pathogenesis of ANEC including genetics. We present a case of a girl who developed this condition with classical clinico-radiologic findings of ANEC secondary to severe dengue infection and could not survive. We report this case with the aim to raise awareness about this fatal complication of dengue infection as dengue has become a global health-care problem.