Frequency of acute kidney injury in tetanus patients of paediatric intensive care unit: a public hospital experience

Background and Objective: Tetanus is a potentially fatal but preventable disease. Mortality is related to severity of the disease, cardiovascular, pulmonary and renal complications. Acute kidney injury [AKI] is a frequent and lethal complication of tetanus. The objective was to determine the frequency of AKI in tetanus patients managed in a public hospital

Methods: Children aged 1-12 years admitted in Paediatric Intensive Care Unit [PICU] with the clinical diagnosis of tetanus over three and half years were recruited for the retrospective study. pRIFLE [Pediatric Risk, Injury, Failure, Loss, End] criteria was applied to all cases of tetanus to categorize them as having AKI or not, on the basis of estimated creatinine clearance [ECCL]. Comparison was done between AKI and non-AKI cases, as well as between AKI survivors and AKI non-survivors. The study was conducted at PICU of Dr. Ruth K.M. PFau Civil Hospital Karachi for tetanus cases admitted during July 2013 to December 2016

Results: During the study period, 44 patients of tetanus were enrolled. Nearly 32 % of tetanus patients developed acute renal dysfunction according to PRIFLE criteria. There were overall 15 [34.09%] expiries among tetanus patients among which nine [60%] had AKI. Oliguria was observed in five [35.71%] cases. All the AKI non-survivors had ECCL below 50% and all had autonomic instability. AKI developed towards the end of first week in three cases, mid of second week in four cases and third week in seven cases. Renal replacement therapy [RRT] i.e. peritoneal dialysis [PD] was done in four AKI cases but it did not improve the outcome. CRP was more than 50 in 24 [54.54%] cases. Ventilatory support was given to 85.71 % with AKI as compared to 66.66 % of non AKI patients

Conclusion: Development of AKI in tetanus is multifactorial. Major contributors are severity of the tetanus itself, presence of autonomic instability, ventilator dependency, and sepsis. Presence of AKI worsens the outcome of tetanus in terms of survival, length of stay, hospital cost and ventilator days

Malnutrition in children: analysis of epidemiology, risk determinants and advances in management

Malnutrition in children is one of the major health challenges faced worldwide but more frequently in South Asian countries including Pakistan. The objective of this review is to analyse the situation of malnutrition, its risk determinants, assessment and management strategies. This review is based on information collected from PubMed, Google scholar, Medline, World Bank, World Health Organization [WHO], United Nations Children's Fund [UNICEF] websites and books. It is concluded that malnutrition status is improving but at a slower pace. Pakistan has a high prevalence of wasting, stunting, and micronutrient deficiencies

The profile and outcome of children admitted in paediatric intensive care unit of a public hospital in Karachi

Objective: To determine the profile and outcome of children admitted in paediatric intensive care unit of a public hospital in Karachi

Study Design: Descriptive / Observational study

Place and Duration of Study: This study was conducted at PIGU of Civil Hospital Karachi from July 2013 to June 2014

Materials and Methods: Data of the admitted patients was collected from the file records. It included demographic profile, admitting diagnosis, length of stay and outcome. Descriptive statistics were applied to describe the results

Results: Overall 243 children were admitted in PICU during the study period. Among which 133 were admitted in 1[st] half and 110 during the later half of the year. 126 [51.85%] were male, whereas 117 were female. According to the age group, 91 [37.44%] were under 1 year where as 152 [62%] were more than 1 year among which 92 were between 1-5 years of age. Majority, 160 [67%] were admitted through emergency. Duration of stay in the hospital was varied, and 176 [72.42%] patients stayed for more than 24 hours, of these, 60 stayed for 3- 5 days. Upon admission, 83 [34.15%] needed ventilatory support. 16 [6.58%] children needed fluid boluses for resuscitation, whereas inotropic support was required by 49 [20.16%] children. Most of the cases i.e. 68 [27.98%] had respiratory illness as reason for admission. CNS diseases were present in 44 [18%] patients followed by sepsis/infection in 35 [14.40%] cases and Cardiovascular diseases in 22 [9%] cases. Out of total admission, 174 [1.60%] were shifted to the ward. Mortality was recorded in 59 [4%] cases, among which 40 occurred during 1[st] half of year and 19 during later half of the year, resulting in mortality of 30% in 1[st] half and 17% in 2[nd] half, respectively. Out of 59 expiries, 24 [40%] died within 1[st] 24 hours due to poor status at admission. Sepsis was the most common cause seen in 42 [71%] of non survivors. 7 cases were referred to other specialized centers for further management after initial stabilization, whereas 3 cases left against medical advice

Conclusion: Respiratory system, central nervous system and infectious disease/sepsis were the commonest reasons for admission. PICU showed improved working in later half of year after its beginning

Diagnostic accuracy of mid upper arm circumference [MUAC] for screening low birth weight babies

Objective: To determine the diagnostic accuracy of Mid Upper Arm Circumference [MUAC] for screening low birth weight babies

Study Design: Cross-sectional study

Place and Duration of study: This study was conducted at the Pediatric Unit II and Gynecology Unit II at Civil Hospital Karachi, Pakistan, from January to June 2012

Materials and Methods: A hospital base study was carried out on full term, singleton 112 live born babies. Birth weight was taken through digital weighing scale as gold standard against anthropometric measurement of MUAC in centimeters

Correlation between MUAC and low birth weight was calculated with 95 % confidence interval

Sensitivity, specificity, positive and negative predictive values were calculated

Results: Out of 112 newborn babies studied, 44 [39 %] were male and 68 [61%] were female. The mean birth weight was 2.316 +/- 0.563 kgs and 51 [45.5%] newborns were low birth weight [LBW]

The mean MUAC was 8.90 +/- 1.08. In low birth weight mean MUAC was 8.41 +/- 0.87; 95% CI [8.21; 8.61] and in normal birth weight mean MUAC was 9.90 +/- 0.70; 95% CI [9.66; 10.13].Pearson correlation between low birth weight and MUAC was found statistically significant [r= 0.858;P-value <0.001]. A cut-off point of <9.3 cm of MUAC showed 81.1% sensitivity and 78.3% specificity

Conclusion: Mid upper arm circumference was statistically significant anthropometric surrogate of birth weight at cut-off point < 9.3 cm in the study population. Further studies are needed to validate the finding of this study in community setting. MUAC is a simple, practicable, quick and reliable indicator for predicting LBW newborns in the community and can be easily measured by paramedical workers in developing nations

Two years' study of Tetanus cases in a paediatric intensive care unit

Objective: To study the demographic and clinical features, outcome, complications and treatment cost of tetanus patients admitted in Paediatirc Intensive Care Unit [PICU] of Civil Hospital Karachi [CHK]

Methods: It is a descriptive observational study conducted at Civil Hospital Karachi from July 2013 to June 2015. Patients of tetanus admitted in PICU during the study period were enrolled. Data was collected from the file records of patients and included the demographic profile, clinical presentation, grade of severity, length of stay, complications and outcome. It also included the cost of treatment. Descriptive statistics were applied to describe the results

Results: During the study period, 23 cases of tetanus were admitted in P.I.C.U. twelve were male and 11 female. Majority of cases [13] belonged to age group 2-6 years. Seventeen cases were unvaccinated and 6 had received only BCG and OPV. None was appropriately vaccinated for age.There were 9 cases of post injury tetanus, 6 of them were males, 5 cases of otogenic tetanus and 9 cases had no clinically identifiable portal of entry. Eleven cases belonged to grade III severity of Ablett classification and 6 had grade IV severity. Mortality in our case series was 26%. Autonomic instability was seen in 17 patients and all of them needed ionotropic support. The estimated cost of per day treatment of a tetanus patient with mechanical ventilation was approximatly 31, 979/Pak Rs and without mechanical ventilation was 20,000/Pak Rs

Conclusion: Tetanus is an entirely preventable disease with a high mortality. Treatment is very costly as compared to vaccination which is free of cost. Complete vaccination and proper wound care is the only option to reduce the ongoing burden of tetanus

Efficacy and adverse effects of oral chelating therapy [deferasirox] in multi-transfused Pakistani children with -thalassemia major

Objective: To determine the efficacy and adverse effects of oral chelation therapy [deferasirox] in multitransfused -thalassemia major patients visiting pediatric thalassemia clinic in Civil Hospital Karachi. Methods: This prospective study was conducted at pediatric thalassemia clinic of Civil Hospital Karachi. Hundred multi-transfused -thalassemia patients registered in the clinic for oral iron chelation therapy were included in the study. Information regarding clinical and laboratory parameters including abdominal pain, jaundice, serum ferritin, creatinine and serum transaminase levels were recorded on a Performa and data was analyzed through SPSS 16. Results: Hundred patients were stratified into two age groups, 54% were below and 46% were above nine year. Majority were males, 62% and 38% were females. Abdominal pain 41%, nausea 31%, vomiting 15%, jaundice 15% and elevated serum creatinine 11.5% were frequently observed clinical adverse effects in this study. Serum glutamic pyruvic transaminase [SGPT] level was statistically significant compared with initial visit and six months after optimal chelation therapy [p=0.030]. Although Serum ferritin was decreased but it was not statistically significant [p=0.929]. Conclusion: Deferasirox is an effective oral chelation agent for -thalassemia major patients. Most common adverse effects of the drug are abdominal pain, nausea, vomiting, and elevation of liver enzymes

Psychosocial determinants of nutritional neglect in a developing country

To determine the demographic features and psycho-social and economic determinants of nutritional neglect in order to suggest interventional strategies. Cross-sectional, observational study. Department of Paediatrics, Dow University of Health Sciences [DUHS] and Civil Hospital Karachi [CHK], from January 2009 to December 2010. All children suffering from nutritional neglect suggested by weight and height less than the third centile for age, and their mothers were recruited in the study through non-probability consecutive sampling. A team comprising of paediatrician, psychologist, medical social worker and social motivator interviewed the mothers and children suffering from nutritional neglect. Information about demographic, social, economic and psychological factors was obtained. The results were analyzed and described as frequency distribution and percentage. A total of 658 children suffering from nutritional neglect were inducted. Around 75% of children were below 5 years of age, 51% were females. Other determinants of nutritional neglect were, large family size [family of > 5 members [84%] young mother [60%], uneducated parents [67% father and 77% mothers being illiterate], low income [77% earning less than Rs. 7000/month], addiction [23%], tobacco smoking [50%] and non-nutritive substance use [51%]. Psychological indicators identified in mothers were depression [70%], anxiety [73%], helplessness [70%], displaced aggression [50%] and insecurity [36%]. Psychological factors identified in children as a secondary outcome were aggression [80%], rebellious behaviour [75%], lack of confidence [70%], lack of social interaction [70%] and paranoid tendencies [60%]. Psycho-social and economic factors are important determinants of neglect. A holistic approach and intervention at multiple levels is required to address these issues

Risk factors for nutritional rickets in children under 36 months: a civil hospital case study

Background: Nutritional rickets is a common problem in Pakistan especially in Karachi with majority of the population living in enclosed housing and slums having limited or no sun exposure. There is a dearth of significant data regarding rickets in Pakistan especially in Sindh which emphasizes the need for further research. This study can be a foundation for other studies regarding strategies for prevention and early diagnosis of rickets

Objectives: To determine the clinical presentation and identify risk factors for nutritional rickets in children less than three years of age

Methods: A cross sectional study conducted in the department of pediatrics DUHS/CHK from June 11, 2007 to December 10, 2007. Fifty patients aged two months to thirty six months presenting with the clinical manifestation of rickets were included in the study. Information recorded included symptoms, socioeconomic status, feeding patterns, sun exposure, clothing, housing and malnutrition. Diagnosis was based on clinical signs, serum levels of alkaline phosphatase, calcium, phosphorus and radiological changes in X-ray wrist joint

Results: Approximately 60% reported a weight for height less than ISO criteria set by WHO. Of the total assessed 58% percent were exclusively breast fed, 30% partial breast fed and 12% on formula milk. Weaning age was not reached in 20% of the children. Complementary feeding initiated late for 40% of the children with 78% percent exposed to sunlight less than 30 minutes per day and. Gross motor delay existed in 30% of children and hypocalcaemia convulsions in 14%. Past H/0 repeated was in 32% had 22% had persistent/recurrent diarrhea

Conclusion: Exclusivity breast feeding to complementary feed, inadequate exposure to sunlight and delayed introduction of complementary foods are the main risk factors for the development of nutritional rickets which can manifest itself in the form of ARI and diarrhea

How frequent are consanguineous marriages?

To determine the frequency of consanguineous marriages in parents and grand parents of all admitted children in a pediatric unit. An observational study. All patients admitted over one year period from January to December 2001 in Unit I of Pediatric Department were included. Information was obtained regarding consanguinity of parents and grandparents of the children Clinically evident inherited disorders were also noted. Consanguinity was found in 72.7% of marriages. First cousin marriages were seen in 87% while second cousin marriages were seen in 12%. Consanguinity was also seen in the grandparents. It was found in 64.15% of maternal and 60.3% of paternal grandparents. Cousin-marriages are a norm in the population studied. Its effect on inherited disorders deserves further studies

Ponderal index of low birth weight babies a hospital based study

To determine the ratio of disproportionate versus proportionate Intra uterine growth retardation among low birth weight babies using the Ponderal index. This was a retrospective study. Medical records of babies with weight <2.5kg delivered in the Obstetric Department were reviewed. The ponderal index was calculated to determine disproportionate and proportionate intra uterine growth retardation among low birth weight babies. A total of 227 babies were included. Male and Female ratio was equal. Sixty seven percent were delivered vaginally. Only 12 mothers [5.3%] had a history of maternal illness. Eighty nine low birth weight babies [39.9%] had a low ponderal index. Ponderal index in fullterm babies was <2.2 in 54.3% and in pre-term <2.0 in 34.9%. Nearly 40% of low birth weight babies had disproportionate body proportions. This group of babies according to foetal origins of diseases may be predisposed to Diabetes, hypertension and coronary artery disease

Applicability of scoring chart in the early detection of tuberculosis in children

To test the applicability of scoring chart to detect children suffering from tuberculosis. Case control study. The study was conducted at the Department of Paediatrics Unit-1, Civil Hospital, Karachi. Included in this study were 50 children in whom tuberculosis [TB] was diagnosed on the basis of history, physical signs, investigations and positive response to anti-tuberculous therapy. Also included in the study were 50 controls admitted with diagnosis other than tuberculosis. Modified Kenneth Jones Scoring Chart [KJSC] was applied to both the groups of children. These children were given a score of 0-7 or above according to the chart. The sensitivity of various parameters used in the KJSC was also tested in both the groups. A score of 1-2 [TB unlikely] was found in none of the cases versus 44% in the controls. Score of 5-6 [TB probable] was obtained in 40% of cases and none in the controls. Fifty-six percent cases had a score of 7 or more [TB unquestionable] versus 0% in controls. Contact with an adult suffering from tuberculosis, physical and radiological signs suggestive of tuberculosis and an exaggerated reaction to BCG vaccine emerged as the most important indicators used in the scoring chart to detect children with tuberculosis. The Kenneth Jones Scoring Chart is a simple cost-effective tool, which can easily be applied to improve the case detection rate in children. In the absence of a gold standard for diagnosing tuberculosis in children and in view of logistic and financial constraints faced by resource constraint countries, like ours, this simple screening tool can be utilized at the health care facilities

Drug resistant malaria

Malaria is a major killer. The problem is heightened by reports of resistance to chloroquine. Rational use of antimalanal is necessary A patient who presented with drug resistance is reported here