Indoor Urban Environment and Conventional Risk Factors for Pediatric Tuberculosis Among 1-12 Years Old Children in a Megacity in Pakistan: A Matched Case-Control Study.

Background: Estimated 1.1 million children developed tuberculosis (TB) globally in 2020. Household air pollution has been associated with increased respiratory tract infections among children. Nonetheless, there are scarce data regarding the association of indoor environment with pediatric TB. Objectives: To determine the association of indoor urban environment and conventional risk factors for pulmonary TB among children 1-12 years and to discern the differences of these factors among younger (1-5 years) and older children (6-12 years). Materials and Methods: We conducted an age-matched case-control study among children in 2 hospitals (tertiary and secondary care) in megacity, Karachi, Pakistan. A total of 143 pulmonary TB cases, diagnosed on Pakistan Paediatric Association Scoring Chart for Diagnosis of Tuberculosis (PPASCT), were compared with 286 age-matched controls (ratio 1:2). Indoor urban environment and other conventional risk factors were ascertained through a questionnaire and analyzed by conditional logistic regression. Results: Overall, being a female child [matched odds ratio (mOR): 2.03, 95% confidence interval (CI): 1.16-3.53], having household TB contact (mOR: 8.64, 95% CI: 4.82-15.49), open kitchen for cooking in household (mOR: 1.99, 95% CI: 1.59-5.66), and poorly ventilated house (mOR: 2.37, 95% CI: 1.09-3.65) increased the risk of TB among children (1-12 years). Open kitchen was a risk factor for younger children (1-5 years), whereas poorly ventilated house and being female child was a risk factor for older children (6-12 years), respectively. Conclusions: This study strengthens the evidence that a poor indoor environment increases the risk for childhood TB. Concerted efforts are needed to improve the indoor air environment in urban areas for prevention of TB in addition to addressing the conventional risk factors.

Antibody-Secreting Cells To Diagnose Mycobacterium tuberculosis Infection in Children in Pakistan.

Reliance on microbiologic methods to diagnose Mycobacterium tuberculosis infection is a suboptimal approach for children due in part to the paucibacillary nature of the disease. A blood-based biomarker assay, such as the mycobacterial-antibody-secreting cell (MASC) assay, could be a major advance for the field of study of pediatric tuberculosis (TB). Children <15 years of age with clinical concern for TB and age-matched children with no concern for TB were enrolled from outpatient clinics in Karachi, Pakistan. MASC, ferritin, and C-reactive protein (CRP) assays were performed, and results were compared among cases and controls, as well as among children with a case definition of "confirmed TB," "probable TB," or "possible TB." MASC responses were significantly higher among children with TB than among controls (0.41 optical density [OD] versus 0.28 OD, respectively, P < 0.001), and the differences were largely driven by the data from children with confirmed TB (P = 0.002). Ferritin and CRP values were significantly higher among those with confirmed TB than among those with the other disease states and controls (P = 0.004 and P = 0.019, respectively). The use of the MASC assay as a blood-based biomarker for TB disease shows some promise among children with microbiologically confirmed disease; however, the performance characteristics for the majority of young children with unconfirmed TB were suboptimal in this cohort.IMPORTANCE Tuberculosis (TB) in children represents a missed opportunity for diagnosis and preventive therapy. The magnitude or burden of disease in children is not fully understood due to our limitations with respect to exploring sensitive diagnostic algorithms. In a setting of TB endemicity in Pakistan, we carried out a proof-of-concept study to evaluate for the first time the performance of B cell analyses by the use of well-defined diagnostic criteria and NIH consensus guidelines as "culture-confirmed," "probable," and "possible" TB groups. In contrast to detection of serum antibody, we focused on mycobacterial-antibody-secreting cell (MASC) detection as a marker of active disease in children with a strong suspicion of TB. Further work exploring a larger panel of inflammatory biomarkers and enrichment of B cells with the objective of increasing the sensitivity of the current MASC assay would lead to the development of a field-friendly assay for timely diagnosis of childhood TB.

Electrolyte imbalance in critically ill paediatric patients.

OBJECTIVE: To determine the frequency and outcome of electrolyte imbalance in seriously ill children admitted in Paediatric Intensive Care Unit (PICU) of a public sector hospital in Karachi. METHODS: All children between the ages of one month to 12 years admitted in PICU from May 2017 to October 2017 were included. Blood samples were drawn to determine the baseline sodium, potassium, calcium, magnesium and phosphorous and followed 24 hourly or earlier, if needed (Those who had imbalance at admission or on subsequent repeat labs as per protocol). RESULTS: A total of 101 children were included in the study. Electrolyte imbalance was seen in 84%. A single electrolyte imbalance was noted in 30.58%. Hypocalcemia was the most frequent abnormality noted in 57.6%. Among the total expiries during the study period 91% had electrolyte imbalance. Mortality within 48 hours and duration of stay was also increased in these patients. CONCLUSION: Electrolyte imbalance is an important prognostic indicator in critically ill patients.

A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines.

INTRODUCTION: Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children-including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. METHODS: Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2-23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. RESULTS: All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. CONCLUSION: Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.

Effectiveness of 10-valent pneumococcal conjugate vaccine against vaccine-type invasive pneumococcal disease in Pakistan.

OBJECTIVE: To assess the effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) against invasive pneumococcal disease (IPD) due to vaccine serotypes of Streptococcus pneumoniae post introduction of the vaccine into the routine immunization program in Pakistan. METHODS: A matched case-control study was conducted at 16 hospitals in Sindh Province, Pakistan. Children aged <5years (eligible to receive PCV10) who presented with radiographically confirmed pneumonia and/or meningitis were enrolled as cases. PCR for the lytA gene was conducted on blood (for radiographic pneumonia) and cerebrospinal fluid (for meningitis) samples to detect S. pneumoniae. The proportion of IPD due to vaccine serotypes (including vaccine-related serogroups) was determined through serial multiplex PCR. For each case, at least five controls were enrolled from children hospitalized at the same institution, matched for age, district, and season. RESULTS: Of 92 IPD patients enrolled during July 2013 to March 2017, 24 (26.0%) had disease caused by vaccine serotypes. Most case (87.5% of 24) and control (66.4% of 134) children had not received any PCV10 doses. The estimated effectiveness of PCV10 against vaccine-type IPD was 72.7% (95% confidence interval (CI) -7.2% to 92.6%) with at least one dose, 78.8% (95% CI -11.9% to 96.0%) for at least two doses, and 81.9% (95% CI -55.7% to 97.9%) for all three doses of vaccine. CONCLUSIONS: The vaccine effectiveness point estimates for PCV10 were high and increased with increasing number of doses. However, vaccine effectiveness estimates did not reach statistical significance, possibly due to low power. The findings indicate the likely impact of vaccine in reducing the burden of vaccine-type IPD if vaccine uptake can be improved.

Frequency of Acute Kidney Injury in tetanus patients of Paedriatic 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.

Dietary Therapy for Von Gierke's Disease: A Case Report.

Von Gierke's disease, also known as glycogen storage disease (GSD) type 1A, is an autosomal recessive disease in which there is an inability to cleave glycogen to glucose because of a glucose 6 phosphate deficiency resulting in hypoglycemia and lactic acidosis. The patient may present with hepatomegaly and signs and symptoms of hypoglycemia. We diagnosed a case of Von Gierke's disease in a seven-month-old female infant who was admitted for abdominal distension, vomiting, and lethargy for a duration of four months with characteristic rounded doll's face, fatty cheeks, protuberant abdomen, and massive hepatomegaly. Lab investigations showed low hemoglobin, low blood sugar level, lactic acidosis, hyperlipidemia, hyperuricemia, mild elevation of liver enzymes, and high anion gap metabolic acidosis. The diagnosis was confirmed with a liver biopsy and dietary treatment was started. This case report highlights the value of dietary therapy in improving the quality of life and survival and minimizing complications.

Evaluation of Xpert MTB/RIF testing for rapid diagnosis of childhood pulmonary tuberculosis in children by Xpert MTB/RIF testing of stool samples in a low resource setting.

OBJECTIVE: Children with tuberculosis (TB) remain underdiagnosed due to difficulty in testing for Mycobacterium tuberculosis (MTB) infection. We evaluated the Xpert MTB/RIF assay for respiratory and stool testing in children for pulmonary TB through a cross-sectional study at tertiary care facilities in Karachi, Pakistan. Fifty children aged 0-15 years screened by a modified Kenneth-Jones (KJ) score were included. Mycobacterial culture of respiratory samples was the microbiological standard against stool Xpert TB results. All positive TB cases were compared against a treatment response standard (TRS). RESULTS: Twelve study subjects were diagnosed by Xpert TB and nine by MTB culture. Compared with culture [gastric aspirates (GA)/sputum (spm)], stool Xpert TB had a sensitivity of 88.9% (95% CI 50.7-99.4) and a specificity of 95% (95% CI 81.8-99.1). Xpert TB stool versus GA/spm had sensitivity of 81.8% (95% CI 47.8-96.8) and specificity of 94.7% (95% CI 84.6-99.9). We found good agreement (kappa scores of >0.8) between stool Xpert, GA/spm Xpert and GA/spm culture. Stool Xpert PPV and NPV against TRS was 100 and 82.1% respectively. Stool Xpert TB is a relatively easy option for diagnosis for pulmonary childhood TB in a high burden low-resource setting.

Development of Pediatric Neurologic Emergency Life Support Course: A Preliminary Report.

BACKGROUND: Acute neurological emergencies (ANEs) in children are common life-threatening illnesses and are associated with high mortality and severe neurological disability in survivors, if not recognized early and treated appropriately. We describe our experience of teaching a short, novel course "Pediatric Neurologic Emergency Life Support" to pediatricians and trainees in a resource-limited country. METHODS: This course was conducted at 5 academic hospitals from November 2013 to December 2014. It is a hybrid of pediatric advance life support and emergency neurologic life support. This course is designed to increase knowledge and impart practical training on early recognition and timely appropriate treatment in the first hour of children with ANEs. Neuroresuscitation and neuroprotective strategies are key components of this course to prevent and treat secondary injuries. Four cases of ANEs (status epilepticus, nontraumatic coma, raised intracranial pressure, and severe traumatic brain injury) were taught as a case simulation in a stepped-care, protocolized approach based on best clinical practices with emphasis on key points of managements in the first hour. RESULTS: Eleven courses were conducted during the study period. One hundred ninety-six physicians including 19 consultants and 171 residents participated in these courses. The mean (SD) score was 65.15 (13.87%). Seventy percent (132) of participants were passed (passing score > 60%). The overall satisfaction rate was 85%. CONCLUSIONS: Pediatric Neurologic Emergency Life Support was the first-time delivered educational tool to improve outcome of children with ANEs with good achievement and high satisfaction rate of participants. Large number courses are required for future validation.

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 & 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.

Effective testing for pulmonary tuberculosis using Xpert MTB/RIF assay for stool specimens in immunocompetent Pakistani children.

OBJECTIVE/BACKGROUND: Childhood tuberculosis (TB) is largely a paucibacillary disease and difficult to diagnose. It is difficult to obtain a sputum or gastric aspirate (GA) sample, and patients are often undiagnosed and treated empirically. Stool is a noninvasive specimen not usually used for TB testing in Pakistan. We investigated the value of Xpert MTB/RIF to diagnose Mycobacterium tuberculosis (MTB) in children with pulmonary TB cases, by performing comparative testing of GA and stool samples. METHOD: We recruited 60 children aged 1-15years, suspected of TB, from the Department of Pediatrics, Civil Hospital, Karachi, Pakistan and The Aga Khan University Hospital, Karachi, Pakistan. All were immunocompetent. Patients had a Kenneth Jones TB score of ⩾5. Paired GA/sputum and stool samples were collected for testing. All GA samples were tested by Xpert MTB/RIF assay and MTB culture, while stool was tested by Xpert MTB/RIF. RESULTS: The study participants included 27 males and 23 females with a mean age of 6years and a mean TB (Kenneth Jones) score of 7. Stool was received in the laboratory within 1-2days of the GA sample for all but one participant, who expired. The rates of MTB detection were as follows: 22% (11 cases) based on Xpert MTB testing of GA, 21% (10 cases) based on MTB culture of GA, and 21% (10 cases) based on Xpert MTB testing of stool. No rifampicin resistance was detected. Overall, there was concordance between testing of GA and stool. One case had GA with low positive Xpert and positive MTB culture, but negative stool Xpert result. In another case, there was low positive GA Xpert, positive GA MTB culture, and positive stool Xpert. A positive Xpert MTB stool test was associated with a higher TB score (>5) and a greater bacillary load. All 11 cases of TB diagnosed were put on antituberculous therapy and responded well to treatment. CONCLUSION: Use of Xpert MTB/RIF assay for stool-based diagnosis of pulmonary TB in immunocompetent children is useful in a resource poor setting. This is a valuable and noninvasive diagnostic alternative for the diagnosis of childhood TB and can be adapted by pediatric arms of national TB programs.

Pediatric Oxygen Therapy: A Clinical Update.

Oxygen therapy is a life-saving, medical intervention in the management of hospitalized children. The goal of oxygen therapy is to prevent or treat tissue hypoxia. Oxygen should be prescribed according to the principles of drug prescription, however, use of oxygen in clinical practice is often inappropriate without knowledge of its potential risks and benefits. This article summarizes practical aspects of clinical use of oxygen in terms of indication, administration, and monitoring, weaning, discontinuation and oxygen toxicity to rationalize therapy and achieve maximum benefits.

Efficacy and adverse effects of oral chelating therapy (deferasirox) in multi-transfused Pakistani children with ß-thalassemia major.

OBJECTIVE: To determine the efficacy and adverse effects of oral chelation therapy (deferasirox) in multi-transfused ß-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 ß-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 ß-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.

OBJECTIVE: To determine the demographic features and psycho-social and economic determinants of nutritional neglect in order to suggest interventional strategies. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Department of Paediatrics, Dow University of Health Sciences (DUHS) and Civil Hospital Karachi (CHK), from January 2009 to December 2010. METHODOLOGY: 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. RESULTS: 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%). CONCLUSION: Psycho-social and economic factors are important determinants of neglect. A holistic approach and intervention at multiple levels is required to address these issues.

Fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder of the connective tissue characterized by progressive disability as a result of extensive extra skeletal enchondral bone formation and malformed big toes which are often monophalangic. Occasional features include short thumbs, fifth finger clinodactyly, malformed cervical vertebrae and mild mental retardation. Beginning during childhood, FOP progressively immobilizes all the joints through adult life, rendering movement impossible. Currently, there is no effective prevention or cure for this debilitating disease. Since it has an autosomal dominant inheritance, our concern is to highlight prompt genetic counseling in the concerned families although many sporadic cases have also been identified.

Community based nutritional rehabilitation of severely malnourished children.

OBJECTIVE: To improve nutrition of malnourished children in the community, using home based treatment. METHODS: A prospective cohort study was conducted in a squatter settlement of Karachi (Khuda Ki Basti). The study was conducted from August 2006 to March 2007. All children <5 years who were <-3sd weight for height were included as per WHO guidelines. After initial screening for complications, the children were provided with high density diet (HDD). Daily weight, amount of HDD consumed and complications were recorded. RESULTS: A total of 24 children were included in the study. Eleven children (45.8%) reached - 1SD at the end of 3 months while 10 patients (41.6%) took 4 months. Twenty two patients (91.6%) were at the median weight for height by the end of 5 months. CONCLUSION: Home based treatment with locally available foods can be used successfully to rehabilitate severely malnourished children.

Female epispadias.

Female epispadias without exstrophy is a rare malformation occurring in 1 in 117,000 male and 480,000 female population. It is imperative that a thorough local examination be performed ideally at birth so the diagnosis and the later psychosocial and psychosexual problems could be prevented. Although, on occasions when the apparent malformation is not that predominant, epispadias can be missed at birth and is diagnosed when the child (usually female) remains wet after toilet training. Reconstructive surgery of the urethra and bladder neck improves the outcome in case of early intervention.

Awareness among parents of children with thalassemia major.

OBJECTIVE: To determine the awareness among parents of children with thalassaemia major (TM) regarding the disease. METHODS: This (cross sectional) study was conducted at Paediatric OPD of Civil Hospital Karachi from May 2007 to October 2007. Parents of thalassaemic children presenting to out patient department, receiving blood transfusion from Patient Welfare Association (PWA) were interviewed using a pre designed questionnaire. Informed verbal consent was taken from the parents. Questions regarding duration of illness, awareness regarding screening of blood, mode of transmission of disease, prevention and treatment were asked. RESULTS: A total of 120 care takers were questioned. Majority was of low socioeconomic class and 66.7% were illiterate. Although nearly 100% of the patients were receiving blood transfusions either from PWA or Hussaini blood bank or both, only 15.8% knew the importance of blood screening. Knowledge regarding desferrol was present in 55% of the patient's parents but only 10.9% were receiving it adequately. Only 15% knew that thalassaemia is an inherited disorder and family screening of the siblings and antenatal diagnosis in subsequent pregnancies was done in 5.8% and 5% respectively. CONCLUSION: Awareness of parents regarding the disease was inadequate. General public and parents of thalassemic children should be sensitized in this regard.

Dengue fever outbreak in Karachi 2006--a study of profile and outcome of children under 15 years of age.

OBJECTIVE: To evaluate children with serologically confirmed Dengue fever in order to identify common clinical features, progress of disease, grades of severity and outcome of cases during the outbreak in 2006. METHODS: A cross-sectional, descriptive study was conducted on serologically positive children with Dengue fever (DF) admitted in Civil Hospital Karachi and Liaquat National Hospital between October and November 2006. Various clinical features and laboratory parameters were analyzed for frequencies. Data was also evaluated to identify the common clinical types and grades of infection as classified by WHO. RESULTS: A total of 35 children were evaluated in the study. Mean age of children was 8.3 +/- 3.5 years and majority was male (54%). Sixty five percent were under 10 +/- 3.5 years of age. Frequent clinical features included fever (97%), vomiting (68%), abdominal pain (68%) and rashes (65%). Gastrointestinal bleeding (61%) and epistaxis (26%) were commonest haemorrhagic manifestations. Thrombocytopenia (86%), anaemia (57%) and Leucopenia (43%) were common laboratory findings. Leukocyte count improved in 2 to 7 days and Platelet count in 2 to 8 days. Dengue haemorrhagic fever (DHF) was seen in 22 children (62%). Majority had Grade-II severity. Mortality was 1 (3%) out of 35 patients. CONCLUSION: 2006 outbreak of Dengue infection in Karachi showed slight difference in clinical features and course of disease compared to epidemics in other regions, thereby, indicating the need for continuous seroepidemeological surveillance.

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

OBJECTIVE: To test the applicability of scoring chart to detect children suffering from tuberculosis. DESIGN: Case control study. PLACE AND DURATION OF STUDY: The study was conducted at the Department of Paediatrics Unit-1, Civil Hospital, Karachi. SUBJECT AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.