Caracterización genotípica de Staphylococcus aureus resistente a la meticilina prevalente en hospitales de Pakistán / Genotypic characterization of prevalent methicillin resistant Staphylococcus aureus in Pakistani community hospitals / Caracterização de Staphylococcus aureus resistente à meticilina prevalecente em hospitais da comunidade no Paquistão

El gen de la proteína A se usó como marcador genético para la caracterización de aislados de Staphylococcus aureus resistentes a la meticilina (SAMR). De un total de 130 aislados de Staphylococcus aureus, 90 fueron identificados como SAMR y 81 de éstos se pudieron caracterizar por tipificación spa. Todos estos aislados fueron obtenidos de cinco Hospitales Nacionales de la Comunidad. Se utilizaron dos juegos diferentes de cebadores para amplificar la región-X del gen de la proteína A en las cepas de SAMR. Un conjunto de cebadores, spa-F/spa-R ha identificado tres tipos de repeticiones diferentes, a saber, 7 repeticiones (spa 2), 8 repeticiones (spa 3) y 10 repeticiones (spa 4) y otro conjunto de cebadores, spa-1113F/spa-1514R ha identificado 4 tipos de repeticiones diferentes, a saber, 6 repeticiones (spa 1), 15 repeticiones (spa 6), y 17 repeticiones (spa 7) y 19 repeticiones (spa 8). Se identificó la repetición 11 (spa 5) con ambos conjuntos de cebadores. Los tipos de SAMR esporádicos que portaban las repeticiones 6, 7, 10, 17 y 19 fueron poco prevalentes mientras que los SAMR epidémicos con 8, 11, y 15 repeticiones fueron más prevalentes y se los consideró involucrados en la transmisión entre los pacientes dentro de los diferentes hospitales. Este trabajo concluye que la técnica spa es lo suficientemente eficiente como para diferenciar las cepas epidémicas, esporádicas y aquéllas que se transforman lentamente de esporádicas a epidémicas.

Protein A gene was used as a genetic marker for the characterization of Pakistani methicillin resistant Staphylococcus aureus (MRSA) isolates. Out of a total of 130 Staphylococcus aureus isolates, 90 were identified as MRSA and of these 90 MRSA, 81 MRSA isolates were characterized by spa typing. All of these isolates were collected from five National Community Hospitals. Two different sets of primers were used to amplify the X-region of Protein A gene in MRSA strains. One set of primers i.e, spa-F/spa-R identified three types of different repeats viz., 7 repeats (spa 2), 8 repeats (spa 3) and 10 repeats (spa 4) and another set of primers i.e. spa-1113F/spa-1514R identified 4 types of different repeats viz., 6 repeats (spa 1), 15 repeats (spa 6), and 17 repeats (spa 7) and 19 repeats (spa 8). Repeat 11 (spa 5) was identified with both sets of primers. Sporadic MRSA types carrying 6, 7, 10, 17 and 19 repeats were less prevalent, while the epidemic MRSA with 8, 11 and 15 repeats were more prevalent and considered to be involved in transmission among the patients within different hospitals. Research work concludes that spa technique is efficient enough to differentiate spa strains carrying variations in general and those slowly transforming from sporadic to epidemic outbreak in particular.

O gene da proteína A foi usado como marcador genético para a caracterização de isolados de Staphylo­coccus aureus resistentes à meticilina (SAMR). De um total de 130 isolados de Staphylococcus aureus, 90 foram identificados como SAMR e 81 destes puderam se caracterizar por tipificação spa. Todos estes isolados foram obtidos de cinco Hospitais Nacionais da Comunidade. Utilizaram-se dois jogos diferentes de cevadores para amplificar a região-X do gene da proteína A nas cepas de SAMRUn conjunto de ce­vadores, spa-F/spa-R tem identificado três tipos de repetições diferentes, a saber, 7 repetições (spa 2), 8 repetições (spa 3) e 10 repetições (spa 4) e outro conjunto de cevadores, spa-1113F/spa-1514R tem identificado 4 tipos de repetições diferentes, a saber, 6 repetições (spa 1), 15 repetições (spa 6), e 17 repetições (spa 7) e 19 repetições (spa 8). Foi identificada a repetição 11 (spa 5) com ambos os conjuntos de cevadores. Os tipos de SAMR esporádicos que tinham as repetições 6, 7, 10, 17 e 19 foram pouco prevalecentes enquanto que os SAMR epidêmicos com 8, 11, e 15 repetições foram mais prevalecentes e são considerados envolvidos na transmissão entre os pacientes dentro dos diferentes hospitais. Este trabalho conclui que a técnica spa é o suficientemente eficiente como para diferenciar as cepas epidêmicas, esporádicas e aquelas que se transformam lentamente de esporádicas em epidêmicas.

Childhood primary angiitis of the central nervous system

To analyze the clinical course and magnetic resonance angiographic [MRA] abnormalities in children with primary angiitis of the central nervous system [cPACNS]. Cohort study. Neurosciences and Neuroradiology Department of the Children's Hospital, Lahore, from January 2009 to December 2010. The cohort comprised consecutive patients diagnosed as having cPACNS based on clinical findings and identification of arterial stenosis on magnetic resonance angiography [MRA] in the absence of an underlying condition that could cause these findings. The treatment protocol for ischaemic infarcts consisted of induction therapy with intravenous steroids pulses and intravenous immunoglobulin followed by maintenance therapy with azathioprine and low dose aspirin. When indicated, they were treated with anticoagulants at least for 4 weeks along with induction therapy. Patients were followed at a single centre and systemically assessed for clinical presentation, classification of disease as progressive or non-progressive, adverse effects of anticoagulants, aspirin, azathioprine and their hospital course. Sixty-eight children with medium-large vessel cPACNS [62% boys, 38% girls] with mean age of 8.5 +/- 3.5 years were enrolled in this study. Motor deficit [70%]; headache [64%] and fever [20%] were the commonest symptoms; whereas hemiparesis [60%]; seizures 55% [focal 35%, generalized 20%] and decreased conscious level [30%], were the commonest neurological findings. Neuroradiological findings were ischaemic strokes in 50 [73.5%], haemorrhagic strokes in 10 [14.7%] and ischaemic haemorrhagic lesions in 8 cases [11.8%]. Angiographically 51 [51/68, 75%] of the cohort had non-progressive [obliterative] and 17 [17/68, 25%] had evidence of progressive arteriopathy at the time of admission. No secondary haemorrhagic lesions were documented among infarcts strokes, which were treated with heparin and oral anticoagulants. Outcome was survival in 56 cases [81.5%] and death in 12 cases [18.5%]. All survivors were discharged on long-term oral aspirin; 15 of them were also commenced on azathioprine. Neurological findings among the 56 survivors were; normal 20%, minor disabilities in 25%, moderate disabilities in 20% and severe disabilities in 35%. The spectrum of cPACNS includes both progressive and non-progressive forms with significant morbidity and mortality. This treatment protocol of immunosuppressive therapy may improve long-term neurological outcome in children with medium-large vessel childhood primary angiitis of the CNS

Ventilator-associated pneumonia in children

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. Cross-sectional, observational study. Medical ICU [MICU] of the Children/'s Hospital and Institute of Child Health, Lahore, from August 2008 to March 2009. 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 mm[3], 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. 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]. 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

Clinical spectrum of infantile spasm at presentation

To determine the clinical and EEG findings in children with infantile spasms at their initial presentation to the Neurophysiology Department, Children's Hospital, Lahore, Pakistan. Observational study. The Neurophysiology Department, Children's Hospital, Lahore, Pakistan, from January 2008 to December 2010. Children aged

Childhood epilepsy

To determine the community-based prevalence of childhood epilepsy and its treatment gap in rural and urban population in Punjab, Pakistan. Cross-sectional study. Gujranwala District, from March to June 2007. Ten out of 52 Union Councils of District Gujranwala, Pakistan, were randomly selected. Field officers, specifically trained for screening children with active epilepsy, performed a door-to-door survey in the selected Union Councils using area vaccinators as key informants. Final confirmation of active epilepsy and treatment details were ascertained by a qualified paediatrician and a paediatric neurologist, where required. Treatment gap was defined as relative [when treated inappropriately] and complete [complete lack of treatment]. Among a total, under 16 years population of 92254, prevalence of childhood epilepsy was found to be 7.0/1000 [n=643] with similar distribution between urban and rural residents. Up to 66% [n=424] patients were being managed by an unqualified person including paramedics and faith healers. Treatment gap was found in 88% [n=566] patients. Childhood epilepsy is common in both urban and rural areas of District Gujranwala. Area vaccinators may be incorporated into screening and referral program to bridge the treatment gap utilizing minimum available resources

Predictors of clinical course of subacute sclerosing panencephalitis: experience at the children's hospital, Lahore

To determine the clinical course of Subacute Sclerosing Panencephalitis [SSPE] and different factors affecting the clinical course. Descriptive study. The Children's Hospital, Lahore, from October 2005 to May 2008. All serologically confirmed patients of SSPE were registered and clinical staging of these patients were done from stage-I to stage-IV. Clinical course of these patients was classified by using neurological disability index as fulminant, acute, subacute, and chronic course. Clinical course was analyzed for any difference with age, gender, immunization for measles, measles infection, nutritional status and correlation with age of onset of SSPE, [Spearman's correlation], using statistic package for social science [SPSS] V. 14. A total of 57 cases [41 males, 16 females] with mean age of 7.45 years were studied. Forty [71.4%] of them were vaccinated with single dose at about 9 months of age, 41% [23/57] had measles infections 2 years of age. Using the Neurology Disability Index for these patients 10.5% had fulminant, 17.5% had acute, 49.2% subacute and 22.8% had chronic course. Age, gender, age at measles infection, SSPE onset age and nutritional status were poor predictors of clinical course of SSPE. Unvaccinated patients showed significantly more rapid course of disease [p = 0.04]. Clinical course of SSPE cannot be predicted at the onset of this catastrophic disorder. Children not immunized against measles had a significant rapid course of disease

Clinical profile of subacute sclerosing panencephalitis

To describe the clinical manifestations of subacute sclerosing panencephalitis in children. Case series. This study was conducted in the Department of Neurology at The Children's Hospital and the Institute of Child Health, Lahore, from April 2005 to April 2007. Fifty patients were diagnosed as subacute sclerosing panencephalitis during the study period. Their diagnosis was based on a detailed history, clinical examination, presence of antimeasles antibodies in Cerebrospinal Fluid [CSF] and typical electroencephalogram [EEG]. The findings were described as average, mean and percentages. Fifty patients were included in this study. The average age of the patients was 8 years. Thirty-eight [76%] were males and 12 [24%] were females. The average duration of symptoms before presentation was 66.72 days. History of measles infection was present in 31 patients [62%] and measles vaccination in 43 patients [86%]. Motor regression was present in all [100%] patients and cognition decline in 43 patients [86%]. Seizures were focal [10%], generalized tonic-clonic [16%] and myoclonic [74%]. Burst-suppression pattern Electroencephalogram [EEG] and the antimeasles antibody in CSF were positive in 100% of patients. SSPE is an indicator of high incidence of measles infection among the paediatric population even among vaccinated children. Males are more common sufferers. SSPE can present with different types of seizures, cognition decline and motor regression being supported by suggestive EEG and presence of anti-measles antibodies in CSF

Predictors of intractable childhood epilepsy

To determine the prognosis of seizures in epileptic children and identify early predictors of intractable childhood epilepsy. Case-control study. The Epilepsy Centre of the Children's Hospital Lahore, from February 2005 to April 2007. 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. 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. 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

Diagnostic role of EEG in children having unprovoked seizures, experience at the neurophysiology department, The children's hospital, Lahore

Although advances in imaging technology offer ever-increasing diagnostic accuracy, the electroencephalogram [EEG] retains its importance and is the cornerstone for the diagnosis and treatment of epilepsy. A cross-sectional descriptive study was conducted at Neurophysiology Department of The Children's Hospital, Lahore. Our aims were to find out the different types of epilepsies diagnosed on EEG in children referred for interictal EEG with recent clinical diagnosis of epilepsy. Out of 645 children referred for EEG after seizures, 415 [64%] were males and 230 [36%] were females, 21% had their first seizure before one year of age, 54% of them were between the ages of 1-5 years and 46% of them were more than 5 years of age. We found normal interictal EEGs in 54% whereas 46% children had abnormal EEGs. So in addition to supporting the diagnosis of epilepsy, EEG has significant potential to classify epileptic seizures

Early predictors of intractable epilepsy in children: a case control study

Case control, Hospital based. Site: Epilepsy Centre, The Children's Hospital, Lahore-Pakistan. From 1st Sept 05 to 30th Nov 06 Knowing the prognosis of epilepsy in children would undoubtly influence the treatment strategy. All the children, age 1 year to 16 years receiving anti-epileptic drugs for their idiopathic or cryptogenic epilepsy were the study population. After six months of commencement of treatment various factors associated with well control the ["controls"] and intractability the ["cases"] were analyzed and a univariate comparison was done between various factors for these two groups. Over a period of 14 months, 520 children, 33% the "control" and 67% the "cases" among these patients were enrolled for this study. Statistically, male gender history of birth asphyxia, initial seizure type, past head trauma, previous CNS infection and family history of epilepsy are not the risk factors, whereas seizures starting in infancy, seizures episodes >10 before commencing treatment, neonatal seizures and neurological deficit present at presentation were the risk factors for intractable epilepsy. Myoclonic seizures, status epilepticus before starting treatment and infantile spasm were seen in the "case" group only. We conclude children having risk factors for intractable epilepsy have poor prognosis and recommend that such children should be referred to epilepsy centre as soon as possible

Neurofibromatosis type II: a rare neurocutaneous syndrome

Neurocutaneous syndromes are heterogeneous group of disorders with abnormalities of central as well as peripheral nervous system. Neurofibromatosis type II [NF-II] is an autosomal dominant neurocutaneous syndrome rarely diagnosed in pediatric population. Diagnosis is based on clinical history and radioimmaging. We present a 14 years old boy with headache and decreased hearing, who turned to be a case of neurofibromatosis type II

Plasma lipid profile in sarcoma patients

Objective of the present study was to observe plasma lipid profile [triglycerides, cholesterol, LDL-cholesterol and HDL-cholesterol] in sarcoma patients. 120 subjects were included in the project. The subjects comprised of two groups; first as Controls [60 in number] and the second as Patients of Sarcoma [also 60 in number]. Fasting blood samples were collected for estimation. Sarcoma patients showed highly significant [P<0.01] decrease, when compared with the normal control subjects

Spectrum of malaria in hajj pilgrims in the year 2000

This study was carried out to investigate the country wise distribution of malarial parasite in Muslim pilgrims. This study was conducted at Ajyad Hospital, Makkah Al-Mukarmah, Saudi Arabia during peak Hajj season, from February to March 2000. The peripheral blood smears for malarial parasites were examined from one hundred and thirty patients suspected to be suffering from malaria. A positive identification of malarial parasite was possible in 19.2%. Seventy-six% patients were suffering from Plasmodium falciparum infection, while 24% had Plasmodium vivax infection. Fifty% of patients from Sudan and Saudi Arabia had P. vivax malaria while in the rest of the countries only P. falciparum infection was found. The patients presented with protean clinical manifestations. Conclusions: Malaria is prevalent in many Muslim countries and the frequency of falciparum species seems to increase as compared to vivax malaria. The majority of falciparum malaria patients develop haematological complications