The Diagnostic Association of Radiological and Clinicopathological Parameters in Community-Acquired Pneumonia in Children: A Cross-Sectional Study.

Background Globally, pneumonia is one of the significant causes of death in children under the age of five years. Assessment of disease severity is essential for clinical decision-making. Clinicians in resource-limited settings use the WHO Integrated Management of Childhood Illness (IMNCI) guidelines to diagnose and treat pneumonia. Chest X-rays and blood biomarkers are frequently performed in children presenting with pneumonia, but their role in clinical decision-making is limited. Objective To evaluate the association of chest X-ray results, clinical parameters, and blood inflammatory biomarkers with the severity of community-acquired pneumonia (CAP) in children to decide which tests are helpful in accurately classifying the severity of pneumonia. Methods This cross-sectional, analytical study was conducted at the Combined Military Hospital, Lahore, among 421 children aged two months to five years who were admitted with complaints of cough and difficulty breathing and were COVID-19 negative. Data was collected through a structured questionnaire, including demographic information and clinical categorization of pneumonia severity using WHO criteria, SpO2 levels, chest X-rays, complete blood count (CBC), and C-reactive protein (CRP) levels obtained within 24 hours of admission. Statistical evaluation of 323 children was done using SPSS version 26, and analysis of variance (ANOVA), chi-square test, and Fisher's exact test were applied to determine statistical significance. p-Value <0.05 was considered significant. Results The median age of the study population was eight months (IQR: 3-20 months); 113 (33.1%) were girls and 127 (37.2%) were underweight children. Eighteen (5.3%) patients had no pneumonia, 245 (71.8%) patients had non-severe pneumonia, and 78 (22.9%) patients had severe pneumonia. The clinical features of severe pneumonia were more common in children with radiologic findings of alveolar CAP than non-alveolar CAP (36.2% and 20%, respectively, p: 0.05). A higher percentage of patients with alveolar CAP had CRP >6 mg/dL than non-alveolar CAP (69.9% and 35%, respectively, p < 0.001). Patients with undernutrition (WAZ <-2 SD), hypoxemia (SpO2 <95%), and having CRP >6 mg/dL were associated with clinical features of severe pneumonia (46.1% vs. 33.8%, 100% vs 47.3%, and 67.9% vs 48.5%, respectively, p < 0.05). A significantly greater frequency of a bilateral multifocal distribution (p = 0.020), and the involvement of the right paracardiac region (p = 0.043) and the left lower lobe (p = 0.007) in those with severe pneumonia was observed. Conclusion Clinical diagnosis of pneumonia, along with the assessment of risk factors, including undernutrition and hypoxemia, should be adequate to diagnose pneumonia in children. Chest X-rays and CRP levels can be helpful in hospitalized children for whom physicians have difficulty deciding about antibiotic prescriptions, but their role in routinely classifying the severity of pneumonia in children is limited.

Antibiotic Use for Febrile Children in a Tertiary Care Hospital's Outpatient Department: A Cross-Sectional Study.

Background Irrational prescription of antibiotics is contributing to the antimicrobial resistance crisis in low and middle-income countries. Antibiotic stewardship programs need to be implemented to rationalize the use of antibiotics, but data on antibiotic prescriptions in pediatric outpatient departments is minimal. This study aimed to determine the frequency of antibiotic prescriptions in febrile children attending the Paediatric Outpatient Department (OPD) at Combined Military Hospital, Lahore, and observe the factors affecting the decision to prescribe antibiotics. Methodology A cross-sectional, descriptive study with non-probability sampling in the Department of Paediatrics at the Combined Military Hospital (CMH), Lahore, was conducted over two years. The confidence limit was 95%, and the anticipated population proportion was 32%. The primary outcome was the proportion of children aged two months to 10 years presenting to the OPD with fever who received antibiotics. Further analysis included the effect of patient-level risk factors on antibiotic prescription, especially in children with respiratory tract infections (RTIs). Results Of the 225 children analyzed, 137 (61%) received antibiotics. Of these antibiotic prescriptions, 123 (90%) were second-line antibiotics. Older age (odds ratio (OR) = 2.3, 1.18-4.46), high fever (OR = 2.48, 1.37-4.5), presenting in autumn and winter seasons (OR = 2.85, 1.53-5.3), ill appearance (OR = 2.71, 1.12-6.55), tachycardia (OR = 4.28, 1.22-15.01), and tachypnea (OR = 4.01, 1.14-14.12) were associated with increased likelihood of antibiotic prescription. Antibiotic prescriptions in children with RTIs were associated with lower RTI (OR = 12.96, 3.49-48.08), probable bacterial infection (OR = 12.37, 4.77-30.05), tachycardia (OR = 10.88, 1.28-92.24), tachypnea (OR = 14.73, 3.14-68.99), and increased work of breathing (OR = 7.8, 2.05-29.56). Conclusions The evidence of the widespread inappropriate use of antibiotics in OPDs, particularly for upper RTIs, highlights the need for an antibiotic stewardship program. Antibiotic overprescription promotes antibiotic resistance, prolonging illness and increasing healthcare costs.

Role of Ondansetron in Reducing Methotrexate Intolerance in Patients with Inflammatory Arthritis.

OBJECTIVE: To determine the frequency of intolerance to Methotrexate (MTX) in patients with inflammatory arthritis by using MTX intolerance severity score, and evaluate the effects of Ondansetron in reducing MTX intolerance. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: Rheumatology clinic, Combined Military Hospital (CMH), Lahore, from 1st November 2021 to 30th April 2022. METHODOLOGY: Patients with inflammatory arthritis taking methotrexate regularly for >3 months participated in the study. The patients' age, gender, education level, marital status and smoking history were documented. The disease duration and disease activity was also recorded. Dose/duration/route/frequency and timing of MTX were noted. MTX intolerance was calculated with the use of the Methotrexate intolerance severity score (MISS) questionnaire. Those MTX intolerant patients who reported nausea and vomiting were prescribed ondansetron along with MTX and were followed up for the next 3 consecutive months. RESULTS: Out of 181 patients, 48(26.5%) showed methotrexate intolerance. The predominant symptom was nausea after taking MTX reported in 93.8% of the MTX intolerant patients followed by behavioural symptoms including restlessness and irritability reported among 79% and 77% of intolerant patients respectively. Those methotrexate intolerant patients who mainly had complaints of nausea and vomiting were started on ondansetron on the day of methotrexate and showed a significant reduction in the median of MISS score in the following two consecutive months (p <0.05) while at 3 months the median did not show further reduction as compared to second month (p=0.12). CONCLUSION: Ondansetron prescribed along with methotrexate in patients having complaints of nausea and vomiting with MTX, reduces the intolerance significantly. KEY WORDS: Rheumatoid arthritis, Methotrexate, Ondansetron, Nausea, Arthritis juvenile.

Indicators of child health in pastoral communities in the Karakoram and Hindukush mountains, Pakistan.

Pastoralism is practiced in remote parts of the Karakoram and Hindukush high mountains, which sprawl across Northern Pakistan, with women and children travelling to high pastures with their animals during summer. The pastures are not accessible by road, while glaciers and hazardous terrain accentuate their remoteness. A cross-sectional observational study was carried out along Pakistan's border with Afghanistan's Wakhan province to assess health indicators in children in pastoral communities. A questionnaire was used to collect basic health data; height / length, and weight were also measured. Thirty-five children were included in the study. This paper offers preliminary conclusions about health indicators and access to health care facilities. For children in the pastures, health care, and other amenities entail long and sometimes hazardous journeys. Living at high altitudes with their livestock, food consists almost exclusively of wheat (roti) and dairy products. The most significant finding was severe stunting in 34.2% of the children. This is higher as compared to the national data, and from Gilgit-Baltistan.

Choosing Wisely: Computed Tomography in the Diagnosis of Adolescents With Intrathoracic Tuberculosis.

In a retrospective study of adolescents with intrathoracic tuberculosis (TB), 26 out of the 81 (32%) patients had undergone chest computed tomography (CT). Chest CT was considered unnecessary in 7 (27%), necessary in 7 (27%), and possibly/probably helpful in 12 (46%). Promptly obtaining specimens for sputum smear microscopy, molecular testing, as well as culture for Mycobacterium tuberculosis could avoid several unnecessary CTs.

Vitamin D supplementation and CD4 count in children infected with human immunodeficiency virus.

OBJECTIVE: To evaluate, in a randomized fashion, the impact of vitamin D supplementation on CD4 count and measures of vitamin D homeostasis in children infected with human immunodeficiency virus (HIV). STUDY DESIGN: Children infected with HIV (n = 54) were randomized to receive no supplementation (group 1), vitamin D 5600 IU/week (group 2), or vitamin D 11 200 IU/week (group 3) for 6 months. Viral load, CD4 percent, CD4 count, 25-hydroxyvitamin D (25[OH]D), 1,25-dihydroxyvitamin D, and other measures of vitamin D metabolism were measured at baseline and 6 months later. RESULTS: A total of 53 participants completed the study. The mean age, CD4 percent, CD4 count, and log(10) viral load at baseline were 10.3 ± 3.9 years, 33% ± 10%, 927 ± 468 cells/µL, and 1.63 (95% CI, 0.76-2.50), respectively. The mean baseline 25(OH)D level was 53.1 ± 24.8 nmol/L; 85% of participants were vitamin D insufficient or deficient (<75 nmol/L). Serum levels of 25(OH)D increased significantly in participants who received supplementation with vitamin D (P = .0002 and P < .001 for participants receiving 800 IU/day and 1600 IU/day, respectively), but not in participants who did not receive supplementation (P = .27). Participants treated with 1600 IU/day of vitamin D achieved a higher mean increase in 25(OH)D than participants treated with 800 IU/day (P = .02). However, only 67% of the group supplemented with higher dose achieved vitamin D sufficiency. Vitamin D supplementation did not lead to an increase in CD4 percent or CD4 count. CONCLUSION: In children infected with HIV with relatively preserved immune function, vitamin D supplementation in doses as high as 1600 IU/day does not impact CD4 count. Vitamin D insufficiency is common in this population, and achieving vitamin D serum levels of >75 nmol/L may require a daily intake ≥1600 IU.