Burnout among pediatric residents and junior consultants working at a tertiary care hospital

Objective: To determine the burnout among postgraduate residents' and junior consultants in a tertiary care hospital

Methods: This cross-sectional study was conducted among the postgraduate residents [PGR] and junior consultants [JC] working at The Children's Hospital Lahore in 2018. Participants were asked to complete Copenhagen Burnout Inventory questionnaire about burnout on 5 point Likert scale. '100 [always], 75 [often], 50 [sometimes], 25 [seldom] and 0 [never/almost never or according to intensity ranging from 'a very low degree' to 'to a very high degree'. Data was analyzed using SPSS version 22. Three questions were added related to hospital factors but scored separately. Students t-test and chi square test were used to compare the burnout

Results: A total of 227 participants including 177 PGR and 50 JC completed the questionnaire with a response rate of 84% and 86% respectively. There was a female predominance, 140 participants [61.7%] were female. Majority was from pediatric medicine 173 [76.2%]. The mean personal and work related-burnout was high among PGRs as compared to JCs [18.68+/-5.01 vs 16.62+/-4.57] [p=0.008] and [21.14+/-5.57 vs. 18.56+/-5.52] [p=0.004] respectively. Similarly, there was significantly more burnout among pediatric medicine study participants as compared to surgery and diagnostic in all domains [personal BO; p=0.030, work-related BO; p=0.021, patient related BO; 0.033 and hospital related BO; 0.001]. No difference was noted based on gender and year of training

Conclusion: Tertiary care hospital postgraduate residents and junior consultants face moderate burnout. Postgraduate residents had significantly more burnout as compared to junior consultants and majority were from pediatric medicine

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

Hearing impairment after acute bacterial meningitis in children

Objective: To determine the incidence of hearing loss after acute episode of meningitis in children

Methods: A descriptive study carried out in the Department of Pediatric Medicine of The Children's Hospital Lahore, Pakistan from January 2014 to July 2016. A total of 175 children one month to 13 years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry and culture sensitivity were sent. CT scan brain was done if required. Hearing assessment was done two weeks after admission using otoacoustic emissions in the patients having normal tympanogram. Hearing impairment was classified as sensorineural if otoacoustic emissions were absent while tympanometry was normal

Results: Of 175 children, 58% were males and 42% were females. Mean age was 2.1 years. Orientation as assessed by Glasgow comma scale [GCS] was normal in 63% while 5% had GCS<8 and 32% had GCS between 8 and 15. Signs of meningeal irritation were seen in 58% while focal signs only in 4%. In 15 % cases CT scan was done, out of which 73% showed abnormal findings. Otoacoustic emissions were absent in 22% of cases. Risk factors of hearing deficit were stay duration of more than 10 days [p=0.04], low GCS at presentation [p=0.009] and meningitis with complications [p=0.008]

Conclusion: The frequency of hearing loss is 22% following acute episode of meningitis which necessitates the need for implementation of screening assessment after meningitis in Pakistan. Prolonged stay, low GCS and complicated meningitis are risk factors for hearing impairment

Patient safety awareness among undergraduate medical students in Pakistani Medical School

Objective: To measure the level of awareness of patient safety among undergraduate medical students in Pakistani Medical School and to find the difference with respect to gender and prior experience with medical error

Methods: This cross-sectional study was conducted at the University of Lahore [UOL], Pakistan from January to March 2017, and comprised final year medical students. Data was collected using a questionnaire 'APSQ- III' on 7 point Likert scale. Eight questions were reverse coded. Survey was anonymous. SPSS package 20 was used for statistical analysis

Results: Questionnaire was filled by 122 students, with 81% response rate. The best score 6.17 was given for the 'team functioning', followed by 6.04 for 'long working hours as a cause of medical error'. The domains regarding involvement of patient, confidence to report medical errors and role of training and learning on patient safety scored high in the agreed range of >5. Reverse coded questions about 'professional incompetence as an error cause' and 'disclosure of errors' showed negative perception. No significant differences of perceptions were found with respect to gender and prior experience with medical error [p= >0.05]

Conclusion: Undergraduate medical students at UOL had a positive attitude towards patient safety. However, there were misconceptions about error disclosure among students and patient safety education needs to be incorporated in medical curriculum of Pakistan

Factors contributing to the lack of interest in research activities among postgraduate medical students

Objective: To determine the factors contributing to lack of interest in research activities among postgraduate residents in pediatric medicine

Methods: This cross-sectional survey was conducted at The Children's Hospital Lahore, Pakistan in August 2017. The questionnaire was distributed to 105 postgraduate residents working in pediatric medicine department and 90 of them returned the completed proforma [response rate; 86%]. Data was analyzed by SPSS version 22

Results: Out of 90 residents' females were predominant [n=58/90; 64.4%]. Mean age of the participants was 28.22 +/- 2.092 years. Majority were unmarried [n=57; 63.3%]. The highest mean score [2.31 +/- 0.697] was regarding ''Lack of proper training for research'', followed by ''lack of previous exposure'' [2.26 +/- 0.728] and ''over loaded curriculum'' [2.13 +/- 0.753]. ''Uncooperative faculty'' and ''funding issues'' as a barrier towards research [p=0.016 and 0.014 respectively] was mentioned by males more than females. ''Social and family commitment'' was a significant perceived barrier in married residents as compared to unmarried residents [p=0.001]. The residents in the younger age group were more reluctant to do research due to ''over loaded curriculum'' [p=0.038]

Conclusion: Lack of proper training of research, lack of previous exposure and time management are the major factors affecting resident's research work, whereas married residents face more social/family constraints as compare to unmarried residents

Is human milk feeding protective for retinopathy of prematurity?

Objective: To find the association between breast milk feeding with retinopathy of prematurity [ROP] in preterm infants

Methods: This was a cross sectional study to examine the effects of breast milk feeding on ROP. Premature newborns below 34 weeks from neonatal unit retinopathy of prematurity program during the years 2015 to 2017 of The Lahore General Hospital were included. We recorded the gestational age, birth weight, presence of ROP and the type of feeding [breastfeeding vs. formula milk]

Results: Out of 428 preterm babies 210 [49%] were males. More babies were between 32-34 weeks of gestation 229 [53.5%] as compared to < 32 weeks 199 [46.5%]. Among all 428 preterm infants 19[4.4%] developed ROP. Majority 13 [68.4%] who developed ROP were <32 weeks of gestation [p=0.042]. The mean birth weight of infants without ROP was 1.51 +/- 0.36 kg [95%CI; 1.47-1.55], while it was 1.36 +/- 0.29 kg [95%CI; 1.22-1.50] with ROP and all who developed ROP were < 2kg. The estimated odds ratio of developing ROP for breast fed versus top feeding was [ORs: 0.571, 95% CI; 0.222- 1.489]. There was a trend toward lower incidence of ROP in the group of newborns who received breast-feeding [36.8%] as compared to top feeding [63.2%] but almost similar percentage who didn't develop ROP were breast fed or top fed with statistically insignificant results [p= 0.24]

Conclusions: Slightly lesser percentage of preterm babies who were breast fed developed retinopathy of prematurity

Spectrum of complications in childhood Enteric Fever as reported in a Tertiary Care Hospital

Objective: To find out frequency of various complications in children admitted with Enteric Fever at a tertiary care hospital

Methods: This was prospective cross sectional study, carried out in the Pediatric Medicine department of The Children's Hospital Lahore from Dec 2014 to March 2017. Children of both genders with age range of 6 months to 16 years diagnosed as enteric fever on the basis of clinical features and positive Typhidot, or blood culture were included in the study. All 180 patients were scrutinized for all possible complications. Where ever required and feasible appropriate and relevant investigations were done to document complications. Data was analyzed by SPSS version 20

Results: Mean age of children was 7.2+/-3.38, majority 94 [52.2 percent] were 5-10 years old. Out of 180 patients, complications were noted in 58 [32.2 percent]. Neurological complications 30.7 percent encompassed maximum complications followed by hepatobiliary 24.61 percent, abdominal 16.92 percent hematological 9.23 percent, bone and joints 7.69 percent, respiratory system 6.1 percent and cardiovascular system 4.41 percent. Mortality rate was 1.6 percent. Thrombocytopenia and leucopenia were significantly associated with complications with p value of 0.002 and 0.003 respectively

Conclusion: Enteric fever is causing our children to suffer by its numerous perplexing and fatal complications. The most vulnerable age for enteric fever and its complication is 5-10 years. To combat these issues large scale vaccination remains promising option at least in most susceptible age group

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

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

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

Impact of maternal education, employment and family size on nutritional status of children

Objective: To determine the impact of maternal education, employment, and family size on nutritional status of children

Methods: It was case control study conducted at OPD of children Hospital Lahore, from September 2015 to April 2017. Total 340 children [170 cases and 170 controls] with age range of six months to five years along with their mothers were included. Anthropometric measurements were plotted against WHO growth Charts. 170 wasted [<-2 SD] were matched with 170 controls [>/= -2 SD]. Maternal education, employment and family size were compared between the cases and control. Confounding variables noted and dichotomized. Univariate analysis was carried out for factors under consideration i.e.; Maternal Education, employment and family size to study the association of each factor. Logistic regression analysis was applied to study the independent association

Results: Maternal education had significant association with growth parameters; OR of 1.32 with confidence interval of [CI= 1.1 to 1.623]. Employment status of mothers had OR of 1.132 with insignificant confidence interval of [CI=0.725 to 1.768]. Family size had OR of one with insignificant confidence interval [CI=0.8 -1.21]. Association remained same after applying bivariate logistic regression analysis

Conclusion: Maternal education has definite and significant effect on nutritional status of children. This is the key factor to be addressed for prevention or improvement of childhood malnutrition. For this it is imperative to launch sustainable programs at national and regional level to uplift women educational status to combat this ever increasing burden of malnutrition

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

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: A descriptive study. Place and Duration of Study: Department of Paediatric Medicine. The Children's Hospital. Lahore, from January to December 2012

Methodology: A total 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=0002]. 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 pneumoniae in 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 Gram- positive and Gram-negative bacteria. The most common pathogen in children who died was streptococcus pneumoniae

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

Fibrodysplasia ossificans progressiva

Fibrodysplasia Ossificans Progressiva [FOP] is a rare autosomal dominant disorder characterized by postnatal progressive heterotopic ossification of connective tissue and congenital malformation of big toes. We report a 3-year male toddler with clinical and radiological features of FOP. He was born with bilateral hallux valgus and at the age of 3 years presented with hard swellings over back, scapular region and forehead that were initially inflammatory and then became bony hard. There is also tilting of neck towards the left due to calcification in neck region. The radiographs showed heterotopic ossification in thoracic region, neck, spine and region of hip joint

Juvenile rheumatoid arthritis

To determine the spectrum of clinical presentation, laboratory parameters and drug therapy in patients with Juvenile Rheumatoid Arthritis [JRA]. Case series. The Children's Hospital and The Institute of Child Health, Lahore, from October 2008 to October 2011. All patients who fulfilled the American College of Rheumatology criteria for JRA were enrolled. Their clinical features, investigations done and treatment received for JRA were noted. Statistical analysis of data was done on SPSS version 16.0 for obtaining descriptive statistics. Out of 185 patients, 50.3% [n = 93] were females; 54% [n = 100] were between 10 - 15 years of age. Polyarthritis was found in 71.9% [n = 133] followed by oligoarthritis [22.7%, n = 42] and systemic onset disease [5.4%, n = 10]. Morning stiffness [78%] and fever [68%] were the most common clinical presentations. All patients with systemic onset disease had fever [n = 10] followed by skin rash, hepatosplenomegaly and lymphadenopathy. Uveitis was found in 2 patients, and both belonged to the oligoarticular group. Rheumatoid factor was found in 10.27% [n = 19] of all patients. All patients were given non-steroidal anti-inflammatory drugs [NSAIDs]. Disease modifying agents [methotrexate] were given to 43.8% [n = 81]. Steroids were used in 61% [n = 113] of patients either with NSAIDs alone or NSAIDs plus methotrexate. Disease profile of JRA at the study centre showed that polyarthritis is the commonest type. Recognition of subtypes will help in planning the management of these patients

Pleural empyema in children: prolonged clinical course

Objective: To assess the hypothesis that empyema thoracis is a problem which is often not optimally treated and to analyze evolving experience in clinical presentation, management and outcome in thoracic empyema

Design: Prospective observational descriptive study

Place and Duration of study: Department of Pediatric Medicine of Children's Hospital and the ICH Lahore from February 2008 to October 2008

Patients and Methods: Out of these 50 children 29 [58%] were males and 21 [42%] were females. Age range was from 06 months to 14 years. The mean duration of illness prior to hospital admission was 18 days. Ultrasonography was utilized in the diagnosis of all patients. Chest CT scan was done in 16 [32%] patients. Pleural fluid culture was positive in only 6 [12%] patients. Staph aureus was the predominating organism 4 [8%]. All patients were treated with intra venous antibiotics and tube thoracostomy. Antituberculous medication was given to 6 [12%] of patients. 29 [58%] patients developed complications in the form of localized collection 12[24%], septations 8 [16%], bronchopleural fistula 7 [14%], pneumothorax 1 [2%] and hydropneumothorax 1 [2%]. 12 [24%] patients were shifted to surgery department for decortication. In this study, duration of illness before visiting hospital was significantly associated with complications [p=0.04]

Conclusion: Empyema associated with community-acquired pneumonia is an important cause of morbidity in children. Para pneumonic effusion should be treated aggressively by physicians. Early drainage and proper antibiotics are recommended to prevent progression to late stage and serious complications, which in turn subjects the patient to a major surgery

Scurvy: presenting as musculoskeletal pain

The incidence of scurvy in the paediatric population is very low. This report describes a case of scurvy in toddler girl who was admitted with severe pain in legs and difficulty in walking along with bleeding from gums. After extensive investigation, she was found to have vitamin C deficiency resulting from restrictive eating pattern. There was significant improvement in presenting symptoms and general health after introduction of vitamin C and fresh fruits and vegetables to her diet. Nutrition-based diseases can still occur in any socioeconomic setting. Nutritional screening remains an important part in every child's general health care