Rising Pediatric Morbidity and Mortality in the Developing World.

Pediatric morbidity and mortality are on the rise in certain regions of the world specifically the low-income countries where no goals are being met in this regard. In comparison to the developed countries, the rate of decline in morbidity and mortality is dawdling. Disease trends show that there is a resurgence of diseases that are already major contributors to this healthcare crisis (big players like pneumonia, malaria, and meningitis), whereas no significant decrease is being noted in the others. Seasonal and cyclical trends along with other factors such as antibiotic resistance and deficient vaccination coverage in the low socioeconomic class (due to decreased availability or lack of awareness) can be counted as major precipitating factors and policies should be aimed towards rectification.

Accuracy of Pediatric Risk of Mortality (PRISM) III Score in Predicting Mortality Outcomes in a Pediatric Intensive Care Unit in Karachi.

Background With the advancements in medicine and increasing access to modern technology, pediatric intensive care units (PICU) are becoming a vital part of any health care setting. PICUs play a key role in saving the life of young patients. Various scales have been designed by researchers to aid in predicting the mortality of a patient admitted in PICU. Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) are among the most commonly used scales. Calculating the risk of mortality enables the physicians to classify the patients and helps in identifying which patients require more urgent care and resources.  Methods A hospital-based prospective study was carried out at PICU in a tertiary care hospital in Karachi from December 2017 to June 2019. All patients between the age of one month and 12 years were included in our study after informed consent from parents/guardians. A standard questionnaire was used and the PRISM III score was calculated at 24 hours of admission. All necessary investigations were carried out, and all statistical analyses were carried out using SPSS v.23 (IBM, Armonk, NY). Results A total of 407 patients were included in our study with the majority being males (54.5%). The mean age was 27±33 months. The mean duration of stay of patients in PICU was 80.15±36.58 hours. The mortality rate in our study was 37.35 % (n=152). The need for mechanical ventilation, use of inotropic drugs, higher temperatures, and low Glasgow Coma Scale scores were associated with poor survival. It was noted that as the PRISM III score increased, the mortality rate also increased. In our study, we found that PRISM III had good predictive power in our population. The area under the curve was 0.903±0.016 (p<0.001, 95% confidence interval: 0.872-0.934). Conclusions PRISM III score showed excellent accuracy and predictive ability in our population. There was no significant difference in observed and expected mortality rates in our study. In a resource-limited setting, the prediction models highlight the cases where more medical attention is required and also enable the physicians to assess the prognosis of the patient so adequate measures can be taken beforehand.

Feedback of final year medical students lectures by paediatrician at a Government Medical College of Karachi.

OBJECTIVE: To assess the feedback of final year medical students on paediatric lectures delivered over a year. METHODS: The descriptive, cross-sectional study was conducted at Karachi Medical Dental College, Abbassi Shaheed Hospital, Karachi, and comprised final year medical students who were exposed to the scheduled lectures in paediatrics from April 2016 to May 2017. After the completion of the designated lectures, an evaluation of the lectures was done by the students who rated the lecture(s) on whether the lectures were clear, interesting, easy to take notes from, thought-provoking and relevant to the course. The evaluation was done anonymously on pre designed evaluation forms which were collected by volunteer third year medical students. Data was analysed and expressed as frequencies and percentages. RESULTS: Of the 212 students, 112(52.8%) agreed strongly that the lectures were clear, 50(33%) found them interesting, 56(26.4%) said the lectures were easy to take notes from, for 58(27.3%) the lectures were thought-provoking, and 118(55.6%) found them relevant to the course. CONCLUSIONS: Majority of the students agreed that the lecture was clear and relevant to the course, but the lectures were generally not found to be easy to take notes from.

Michelin Tire Baby Syndrome: A Rare Case with Review of Literature.

Michelin tire baby syndrome (MTBS) is a benign hamartomatous condition with ring-like lesions present on the limbs and trunk. MTBS is a rare genodermatosis. According to our search, only 20 cases have been reported. We present a case of a six-month-old female child, with complaints of fever and seizures. Since birth, she had asymptomatic multiple, asymmetric skin folds on all four limbs, resembling "Michelin Man" logo of the French tire manufacturer. She had microcephaly with characteristic round face hypertelorism, depressed nasal bridge, hypertrichosis with low set ears, a thin down-turned vermillion border of the upper lip, and a short neck. MRI was normal. Clinically, the diagnosis of MTBS was made. In addition, the parents were counseled about the self-limiting course of this disorder. MTBS itself might not be a single disorder but may manifest as a clinical finding associated with other disorders; therefore, a regular follow up of these patients is usually advised.

Frequency of Ocular Diseases in Infants at a Tertiary Care Hospital.

PURPOSE: To determine the frequency of ocular diseases in infants visiting the ophthalmology department of a tertiary care hospital. METHODS: This was a cross-sectional descriptive study conducted in the department of ophthalmology, Abbasi Shaheed Hospital, from January 2015 to May 2016. The study included 377 infants ranging in age from 1 day to less than 1 year who were, selected by a nonprobability consecutive sampling technique. A detailed history was taken, and a complete ocular examination was performed. Descriptive statistics were used to calculate the mean and standard deviation for age. Frequencies were calculated for ocular diseases along with the percentages. Outcome variables included various congenital and acquired diseases such as conjunctivitis, congenital cataract, glaucoma, nasolacrimal duct blockage, squint, trauma, and fundus abnormalities. RESULTS: The mean age of infants was 5.0 ± 3.7 months. There were 196 (52%) males and 181 (48%) females. The sample included 330 (87.5%) full term infants. Acquired ocular diseases occurred in 230 (61%) infants; and congenital diseases, in 147 (39%). The most common ocular disease was conjunctivitis, which occurred in 173 (46%) infants, followed by congenital blocked nasolacrimal duct, which occurred in 57 (15 %) infants. Conjunctivitis was more common among neonates than infants. CONCLUSIONS: Acquired ocular diseases were more common than congenital ocular diseases. The most common ocular pathology was conjunctivitis, followed by congenital nasolacrimal duct obstruction, in infants. Conjunctivitis was more common in neonates than infants.

Emergence of Multi-Resistant Enteric Infection In A Paediatric Unit Of Karachi, Pakistan.

From June 2018, onwards, there has been an upsurge of multi-resistant enteric infections in children admitted from various catchment areas of Abbasi Shaheed Hospital (ASH). This is a serious concern as very few antibiotics are available to treat the children. Children from June 2018 to September 2018 of age groups 5.7 ± 2.84 (range 1.6 to 11 years), referred to ASH, for admission, with clinical suspicion of enteric fever and having received a third generation injectable cephalosporin by a general practitioner, for 5 days or more, with no response, and continuation of fever, were included. A total number of 137 patients had culture proven salmonella typhi, of whom 61(44.52%) showed sensitivity only to meropenem, 45 (32.8%) to azithromycin,13(9.4%)to fosfomycin, 11(8.02%) to Amoxicillin/clavulanic acid, 5 patients showed sensitivity to ceftriaxone(3.64%) and one had sensitivity to amikacin. All patients were treated successfully for 10 days and discharged home. There were no reported complications at follow-up. Multi-Drug Resistance (MDR) enteric fever appears to be a major health concern in Karachi. Mass immunization with oral live attenuated Typhi 21a or injectable unconjugated Vi typhoid vaccine, rational use of antibiotics, improvement in public sanitation facilities, availability of clean drinking water, promotion of safe food handling practices and public health education are vital in the prevention of MDR enteric fever.

Fundamentals required for foundation of a noteworthy PhD in biomedical sciences from Pakistan.

There are only a few Doctors of Philosophy (PhDs) in Biomedical Sciences from Pakistan and there are a number of misconceptions in our country regarding them. This may be due to a lack of knowledge regarding the existence of available programmes or a lack of will or interest in acquiring such a degree. While several PhD programmes exist all over the world, such programmes are lacking in our region even though the Higher Education Commission (HEC) is trying to promote PhD through multiple means and resources. This review discusses the concepts of academicians and clinicians about a PhD, especially in Biomedical Sciences; importance of such a programme; whether Pakistan should have this programme; state of current PhD holders and companies that employ them in well-developed countries e.g. the United States of America. At the same time it also emphasises the need for supervisors to be interested in and promoting availability of PhD programmes, and recognising that there are very few qualified supervisors who have a research experience at an international level.

Toxic metals in maternal blood, cord blood and meconium of newborn infants in Pakistan.

Toxic metals and deficiency/excess of trace elements can have adverse effects on health. The aim of this study was to quantify toxic metals lead, cadmium and trace elements zinc, copper, aluminium (Al) and Iron (Fe) levels in pregnant women, cord blood and meconium of new-born infants from industrial zones of Karachi, Pakistan. Analytical research was performed from 2011-2012 in low socio-economic pregnant mothers and newborn infants from 20 towns near Sindh Industrial Trading Estates, Federal B industrial area and Korangi industrial areas, Karachi, where environmental pollution was anticipated. Blood samples of pregnant women (n = 416), cord blood (n = 309) and meconium (n = 309) were analyzed quantitatively for metals and trace elements. Results indicated that mothers residing in steel towns were found to have the highest levels of lead. Meconium contained high levels of toxic heavy metals and trace elements compared to cord blood and maternal blood. Maternal blood toxic metals were present in high quantities. Therefore, safety measures should be taken when industrial waste is disposed of in order to prevent population contamination.

English Grammar Problems Seen in the Original Articles Submitted for Publication in Annals of Abbasi Shaheed Hospital and Karachi Medical and Dental College.

OBJECTIVE: To find out the frequency and type of English Grammar problems in original articles, submitted for publication in Annals of Abbasi Shaheed Hospital, Karachi. STUDY DESIGN: Across-sectional study. PLACE AND DURATION OF STUDY: Department of Annals of Abbasi Shaheed Hospital and Karachi Medical and Dental College in January 2015. METHODOLOGY: The study evaluated 28 original research articles, published in Annals of Abbasi Shaheed Hospital and Karachi Medical and Dental College during January 2013 to December 2014, for the English language mistakes in the manuscripts. The researchers evaluated English grammar problems in the manuscripts and recorded the details on a predesigned proforma. The data was analysed on SPSS version 19.0. The categorical variables were computed as percentage. RESULTS: It has been observed that all the manuscripts evaluated for English grammar mistakes, demonstrated language mistakes. The mean of mistakes in June 2014 was 14.6 ±2.26, while for December 2014 is 20.5 ±4.76. The mean for the year 2013 issues was 1 ±6.18 for June issue and 13.3 ±3.0 for December issue, respectively. The number of mistakes identified in the manuscripts in descending order included punctuation marks, use of inappropriate tense and voice, use of articles (a, an, the), use of prepositions, wordiness (excessive words), long sentences, spelling mistakes, flow of thought process, incomplete sentences, and frequent use of abbreviations. CONCLUSION: Alarge number of manuscripts revealed inappropriate use of punctuation marks followed by tenses, active and passive voices.

Trend over time; a structural review of articles published in Journal of Pakistan Medical Association from 1953-2009.

OBJECTIVE: To review the articles published in the Journal of Pakistan Medical Association from 1953 to 2009 and to assess the components of each article by a pretested proforma containing a checklist of items based on modified 'Strengthening the Reporting of Observational Studies in Epidemiology' statement. METHODS: The retrospective study was conducted at the office of the Journal of Pakistan Medical Association, Karachi, from February to November 2010. A checklist of items in the modified 'Strengthening the Reporting of Observational Studies in Epidemiology' statement was made after discussion among the authors of the study to finally include a revised checklist of 45 items instead of the checklist of 22 items of the statement. A total sample size of 370 was calculated. Simple randomisation was done for selection of articles from each year. For each article, major and minor items were documented. Data was fed into SPSS version 15. RESULTS: The scientific quality of reporting of most of the components of Introduction, Results and Discussion sections have improved progressively with time (p < 0.001) whereas most components of Methodology have remained consistent. CONCLUSION: A change in trend over time was observed over the study period in major and minor items of the articles in the Journal, showing improved reporting of various sub-components of articles.The modified 'Strengthening the Reporting of Observational Studies in Epidemiology' statement provides a checklist that may be used to improve the quality of articles.

Frequent factors for women and children subjected to sexual assaults presenting at Jinnah Postgraduate Medical Center, Karachi.

OBJECTIVES: To determine the frequent factors in women and children subjected to sexual assaults seeking medical care at Jinnah Postgraduate Medical Center, Karachi. METHODS: A cross sectional study was conducted in the Medico legal Department of Jinnah Postgraduate Medical Center, Karachi, Pakistan. Sexual assault victims seeking medical care and medico legal reports from Jan 2007-June 2010 were included in the study. The sampling technique was non-probability purposive. All women were informed regarding the confidentiality of their records and written informed consent was taken. In case of female children the consent was taken from both parents/guardians. The data was analyzed on statistical package for social sciences version 15. RESULTS: There were 180 women and children examined and interviewed after the Sexual assault. The mean age (years) was 19.24 +/- 7.33. Mostly reported victims were raped and abused both 162 (90%) and only rape was reported in 18 (10%).The physical, local, Abdominal and Pelvic examination showed fresh act of violence in sexual assault victims in 83 (46.1%) cases. The sexual assault was confirmed in 75 (41.7%) cases. CONCLUSION: The fresh sexual assault acts confirmed in 41%. The frequent factors in women and children subjected to sexual assaults were adult women (18-40 Years), two third victims brought by police after 6-24 hours of rape, 90% reported both sexual assault and physical violence, in two third cases no weapon used and no external marks of body injuries observed.

Double outlet right ventricle, atrioventricular canal defect with severe pulmonary artery stenosis: a rare cyanotic congenital heart disease.

Double outlet right ventricle (DORV) is characterised by arousal of the aorta and the pulmonary vessel from the right ventricle, and is always accompanied by a ventricular septal defect (VSD). Our patient, a twenty days-old female child, presented to the Paediatrics Unit I of Civil Hospital, Karachi, with complaints of generalised cyanosis and reluctance to feed since birth. Apart from the fact that the neonate was cyanosed with increased respiration, the physical examination was unremarkable. Two-dimensional echocardiography revealed two atrial septal defects (ASD), a ventricular septal defect (VSD) in the membranous area, continuous with primum ASD, resulting in an atrioventricular canal defect. The aorta was dilated with the pulmonary artery stenosis. The left ventricle was rudimentary, and both of the great vessels were arising from the dominant right ventricle. Despite the rarity, DORV with complex anatomy should be considered among the probable differential diagnoses for infants presenting with generalised cyanosis since birth.

Impact of terrorism on health and Hospital Anxiety Depression Scale screening in medical students, Karachi, Pakistan.

OBJECTIVES: To determine the association of terrorism with psychiatric morbidity by Hospital Anxiety Depression scale among medical students in Karachi, Pakistan. METHODS: The questionnaire based cross-sectional survey was conducted from February to March 2011 and comprised students of the Institute of Physical and Medical Rehabilitation and the Dow Medical College, Dow University of Health Sciences, Karachi. The study tool was a validated Hospital Anxiety Depression scale questionnaire. The data was analysed on SPSS 16. Factor analysis was performed to check which factors had the most influence. RESULTS: Overall there were 1036 respondents. The impact of terrorism on physical, social and mental health was 40 (3.9%), 178 (17.2%) and 818 (79%) respectively. There was an association of terrorism in 980 (84.6%) respondents with psychiatric morbidity. CONCLUSION: There was an association of terrorism with psychiatric morbidity in majority of respondents. The significant risk factors were age, gender, physical, mental and social health and the desire to live in Pakistan.

Medical students perception of their medical environment-expected versus actual perceptions--a cross sectional study.

OBJECTIVE: To compare the expected (perceptions of their environment at the beginning of their 1st year) versus actual perceptions (perceptions at the end of 1st year) of 1st year students at Dow University of Health Sciences. METHODS: The 'expected' perceptions of the students were recorded at the beginning of their 1st year (n = 411) of medical education when they entered the medical school using Dundee Ready Educational Environment Measure (DREEM). DREEM is a validated and self-administered inventory which focuses on learning, teachers, self-confidence and academic as well as social environment. The 'actual' perceptions were then recorded at the end of their first year (n = 405) of education when they had received adequate exposure of their environment. The 2 records were then compared. RESULTS: The total expected DREEM score was 118/200 and the total actual DREEM score was 113/200. The expected domain (Students' perceptions of learning, students' perceptions of teachers, students' academic self-perceptions, students' perceptions of atmosphere, and students' social self-perceptions) scores were 28/48, 26/44, 20/32, 28/48, and 16/28. The actual domain scores were 27/48, 23/44, 19/32, 27/48, 16/28. However both the actual and expected scoring displayed satisfactory environment for learning. Significant differences (p < 0.0001) were found in the two samples. CONCLUSION: In general the results displayed that the students perceived the environment positively but the significant difference found in the two samples, demonstrated that their expectations were not met.

Carbohydrate (CHO), protein and fat intake of healthy Pakistani school children in a 24 hour period.

OBJECTIVE: To determine the frequency pattern of CHO, protein and fat intake in 24 hours by Pakistani school children of different socioeconomic and cultural backgrounds) 6 to 16 years of age. METHODS: The cross-sectional study was a multistage stratified sampling, done in a part of nationwide survey funded by the Higher Education Commission, Pakistan (HEC, Ref no: 20-441/R&D/2008). Sample collection of the study was done from 2006-2009, and growth centile charts have already been published (JPMA 2012; 62:367-77). This is the final paper of the completed project and includes data on only the nutritional status. Final statistical analysis of the nutrition aspect was done from 2012 to 2013 and comprised assessment of quality and quantity of CHO, protein and fats consumed by healthy schoolchildren in a 24 hrs recall (breakfast, brunch, lunch, tea time, dinner and bed time). Food records of 11, 237 school children were subjected to United States Department of Agriculture food exchange list. SPSS 18 was used for statistical analysis. RESULTS: The age range of the study subjects was 6-16 years, and they represented different areas of Pakistan. The consumption of CHO was high (range: 60-74%) compared to protein (10-12%) and fat (18-32%). CONCLUSION: Schoolchildren in Pakistan were found to be taking a deficient amount of protein and fat in their daily diet, while. CHO intake was higher than normal.

Treatment of Hepatitis C Virus Infection in Children Less than 12 Years of Age in Developing Countries.

The treatment of hepatitis c virus (HCV) infection in children is difficult as few options are available. The standard therapy is combination pegylated interferon (PEG-IFN) α-2a or 2b and ribavirin, and the duration of therapy depends on HCV genotype. New oral drug therapies available for adults have still not been approved for treatment in children. Here, we review the causes of HCV infection in children, the therapeutic options for children, and the side effects of these treatments. The problems faced by physicians managing HCV infection in children less than 12 years of age in a developing country are also discussed.

Reasons behind the increase in research activities among medical students of Karachi, Pakistan, a low-income country.

CONTEXT: Previously, in a low-income country with limited resources like Pakistan, biomedical research was conducted mostly by individuals working in private organizations. Recently, there has been an upsurge in the number of medical students conducting research in both private and public medical colleges of Karachi, Pakistan. We investigated student perceptions of the reasons behind the increase in biomedical research among medical students of private and public medical colleges in Karachi, Pakistan. METHODS: This cross-sectional study was conducted at four medical universities of Karachi, using structured data collection tool. Participants included medical students who stated that they were interested in medical research. We assessed how many had been involved in research or stated that they intended to be, and tallied students' stated reasons why they were involved in research. Chi-square analyses were used to assess if year of training, institution, and other factors were associated with the likelihood of past or current actual research involvement. RESULTS: Out of the 398 students with research interest who participated in the study, 349 (88%) stated that they intended to do research projects in their undergraduate years. At the time of the study, only 202 (51%) reported that they had actually conducted research. The reasons given for engaging in research for a minority included personal interest (n = 136; 34%), while majority stated that their motivation was to improve their curriculum vitae (75%) and/or to be more competitive for a residency in the United States (43%). The reasons students gave for involvement in research were related to whether their schools were public versus private and to their year of study. DISCUSSION: According to students' reports, improving one's curriculum vitae to get a strong residency in the USA appeared to be a principal reason for the increase in biomedical research in Karachi. The challenges of research, such as lack of good mentors and increased work-load were reported to affect few students' ability to engage in research.