Foreign body or foreign from body--congenital unilateral lobar hypoplasia of lung

We report a rare case of congenital unilateral hypoplasia of the lung without any other anomaly at Aga Khan University Hospital. A 7-month-old male infant presented in emergency room with respiratory distress. There was no history of cough and wheeze. X-ray revealed left sided non homogenous opacity along with right sided hyperinflation. A suspicion of foreign body was made on chest X-ray but bronchoscopy was deferred in view of bilateral equal air entry and absence of wheeze. CT scan showed left upper lobe hypoplasia. Child recovered with supportive therapy and was discharged home. To the best of our knowledge unilateral lobar malformation of the lung is an extremely rare entity and few cases have been reported so far

Trends of empiric antibiotic usage in a secondary care hospital, Karachi, Pakistan

Objectives: (1) To determine the indications, frequency, and types of antibiotics used in hospitalized paediatric patients at tertiary care hospital and (2) to evaluate whether the prescribed antibiotics were based on the isolation of organism and their sensitivity. Study Design: Descriptive observational hospital based study.Results: A total of 131 patients were included over 6 months of study period, in whom antibiotics were prescribed at the time of admission. The majority were between 1 and 5 years of age. M:F ratio was 1:1. Fever was the commonest symptom (in 84% of cases) followed by gastroenteritis. Blood culture was done in 114 cases (87%) and was positive only in 10 (8.8%). The commonest organism isolated from blood was Salmonella Typhi. Ceftriaxone was found to be the most frequently prescribed antibiotic as an empirical therapy. 102 (77.86%) patients received Ceftriaxone, followed by ampicillin. The antibiotics were probably used on the basis of clinical condition rather than the result of blood culture, as yield of blood culture was quite low.Conclusion: Our study showed an unjustified use of antibiotics regardless of the admission and discharge diagnosis in acute febrile illnesses. Further on, inappropriate practice of using Ceftriaxone was noted in LRTI and pneumonia. Efforts are needed to educate physicians about the rational use of antibiotics

Disease patterns and outcomes of neonatal admissions at a secondary care hospital in pakistan

Objectives: This study aimed to determine the disease patterns and outcome of patients admitted to the neonatal unit of a secondary care hospital in Pakistan from January to December 2009.Methods: Retrospective data from the medical records of all neonates admitted during the study period were reviewed and analysed for age, weight, sex, reason for admission, duration of hospital stay, diagnosis and final outcome. Trends were examined to identify the indicators of inpatient neonatal deaths.Results: The total number of neonates admitted during the study period was 1,554; 979 were male (63%), and 575 were female (37%). A total of 891 patients (57.3%) were born in the hospital while 663 (42.7%) were born elsewhere. The majority were admitted during the first 24 hours of life (51.3%). A total of 13 patients (0.8%) weighed \u3c1 \u3eKg; 85 (5.4%) weighed 1-1.49 Kg, and 587 (37.7%) between 1.5-2.5 Kg. Prematurity and infection were the main reasons for admission (27.9% and 20.33%, respectively), followed by birth asphyxia (13%) and neonatal jaundice (11.3%). A total of 1,287 patients (82.8%) were discharged, 41 left against medical advice (2.6%), 59 were referred to tertiary care hospitals (3.79%) and 106 (6.8%) died.Conclusion: Prematurity, low birth weight, birth asphyxia and neonatal jaundice were the major causes of neonatal admissions. This could be reduced by appropriate antenatal care, timely intervention, and in-time referral to tertiary care centres for the deliveries of all high-risk pregnancies. The major cause of neonatal mortality was prematurity

Atrial thrombus in a premature newborn following cardio-pulmonary resuscitation

Critically ill newborns, whether term or preterm, are at great risk for developing symptomatic thromboembolic disease. Comorbidities like inflammation, DIC, fluctuations in cardiac output, congenital heart disease, as well as central venous or arterial catheters, are the predisposing risk factors. Clinically symptomatic or asymptomatic cases are usually picked up by echocardiography, usually done for other indications. Management usually comprises of observation, heparin therapy, thrombo-embolectomy, and catheter directed revascularization. We present a case of premature neonate who developed thrombus at inter-atrial septum as a possible consequence of cardiopulmonary resuscitation, detected by echocardiography. Conversely, there is always a possibility of paradoxical emboli in neonates with patent foramen ovale (PFO). Subsequent clinical course remained asymptomatic and baby was discharged home after 6 weeks with cardiac follow-up. Atrial septal findings of organized clot/thrombus in asymptomatic newborns need to be correlated with the details of neonatal care. Long-term follow-up is dependent on underlying pathology

Frequency of hypocalcemic fits in children 2 months to 2 years of age, presenting with the first episode of afebrile seizures at hospital settings in urban Pakistan: A cross-sectional study

Introduction: Seizures are common in the pediatric age group, occurring approximately 10% of children. Hypocalcemia is one of the most common metabolic causes of afebrile seizures. The objective of the study was to determine the frequency of hypocalcemic fits in children presenting with the first episode of afebrile seizures from 2 months to 2 years of age. Methods: The study was conducted at the Aga Khan hospital Karachi and its three secondary hospitals including the following sites of Kharadar, Hyderabad, and garden. It was a cross-sectional study. The duration of the study was of 6 months from 18th July 2017 to 18th Jan. 2018. All patients who fulfill the inclusion criteria and visited the Pediatric medicine Department of Aga Khan Hospital, Karachi, and its secondary hospitals were included in the study after ethical approval and informed and written consent. A brief history was taken, clinical examination was done and serum calcium level was sent to the institutional laboratory to reach the outcome i.e. hypocalcemic fits. Result: A total of 85 children presenting with the first episode of afebrile seizures were included. Total of 45 patients (52.98%) were males & 40 patients 2 (47.1%) were females with the mean age were 10.5824 ± 6.84907 months. The hypocalcemic fits were seen in 21 children (24.7%). Discussion: Hypocalcemia is a common cause of afebrile fits in children. Inadequate sun exposure, early age, male gender, low weight, and illiteracy are major risk factors for hypocalcemia

Categorization and frequency of indications for packed cell transfusion in the preterm newborn during the initial hospital stay at a tertiary care hospital: A cross-sectional study

Introduction: Packed cell transfusion is a lifesaving procedure in premature babies as they have more complications as compared to babies who are born at term. Complications related to prematurity increase as gestational age decreases and anemia is one of the complications of prematurity which needs packed cell transfusions. To date, when to transfuse preterm babies and what would be the threshold for hemoglobin and hematocrit is still a point of argument as well as liberal versus restrictive transfusion protocols have been developed but what should be followed still needs more data. In our study, we have observed frequencies of different indications of packed cell transfusion in the neonatal intensive care unit of a tertiary care hospital. This endeavor will help in the establishment of guidelines regarding transfusion and the threshold on which any intervention should be done also it would be a step towards the identification of preventable causes that lead to transfusion and transfusion-related risks and hazards. Objective: To determine the indication of packed cell transfusion and their frequencies in preterm neonates. Study Design: This was a cross-sectional study. Setting: The study was carried out in the neonatal intensive care unit (NICU). Study Duration: The duration of the study was 1 year. Material and Methods: A total of 246 preterm neonates admitted to Aga Khan University Hospital (AKUH) neonatal intensive care unit in the tenure of 1 year, fulfilling the inclusion criteria and requiring packed cell transfusion were included. After the approval from ethical review committee, charts were reviewed for gestational age, birth weight, mode of delivery (normal vaginal or Cesarean-section) were recorded. Indications of packed cell transfusion (intraventricular hemorrhage, infection or sepsis, anemia of prematurity, phlebotomy losses, increase oxygen requirement, hematological causes, other causes of hemorrhage and other causes) were observed and recorded. Pre-transfusion hemoglobin levels (g/dL) and hematocrit levels were also recorded. Other information like number and volume of transfusion and day of life on which transfusion was administered was also documented. Results: A total of 246 critically ill children were enrolled in this study. Of the total, 52.8% were baby boys and 47.2% were baby girls. 57% of babies were born via cesarean section and 43% were born via vaginal delivery. Out of total preterm newborns admitted in NICU, 22.8% were extremely preterm, 35.4% were very preterm and 41.9% were late preterm. Mean gestational age was observed to be 31 (±4) weeks and the mean birth weight of newborns was 1500 (±600) grams. Indications of packed cell transfusion observed in our study are intraventricular hemorrhage 10%, 26% sepsis/infection, 4% hematological disorders, 12.8% anemia of prematurity, 25.2% was related to increase in oxygen requirement, 13% other hematological causes and 9.3% other causes. Conclusion: An increase in oxygen requirement and anemia of prematurity were the indications that were observed in the extremely preterm and very preterm groups. Sepsis and increase oxygen requirement are some of the major causes of transfusions observed in the late preterm group. Preventable indications can be one of the areas that can be worked on and will reduce the need for transfusion in preterm babies with subsequent prevention of transfusion-associated risks

Maternal risk factors and short term outcome of prematurity: A descriptive study at a secondary care hospital

Background: Approximately 15 million babies are born premature (before 37 weeks of gestation) and 1 million babies die due to prematurity complications every year. Less is known about risk factors of prematurity in middle and low-income countries. The prevalence of prematurity ranges from 5% - 18%. Objective: To determine the prevalence of premature births and to assess the rate of survival, along with the morbidity, among preterm newborns. Furthermore, to document our experience with different gestational age groups of preterm births; and to analyze the association among these strata and their clinical outcomes. Study Design: A descriptive study. Place and Duration of Study: The Aga Khan Maternal and Childcare Centre Hyderabad, Pakistan, from 1st January 2017 to 31st December 2018. Methodology: All pregnant women registered at the obstetric clinic before 24 weeks of gestation having at least three subsequent visits at the same clinic were included in the study. The women who were lost to follow up before completing three visits were excluded from the study. All un-booked women were also excluded from the study. Demographic profile was recorded including maternal age, parity, no of visits at the clinic, gestational age, mode of delivery, birth weight and pregnancy outcome. Newborns were subsequently followed at nursery or well-baby till discharge. Further subgroups were made for gestational age to assess the frequency of various morbidities in each group. Results: One thousand and ninety-one (1091) women were included in the study period that fulfilled the inclusion criteria. Two pregnancies were terminated before 24 weeks due to major congenital malformations. The prevalence of prematurity was recorded as 13.4% (146/1089). Perinatal mortality rate (no of stillbirths plus the number of early neonatal death/1000 live birth) was 17 (15.6/1000 live births) out of them, 12 were still births and 5 were early neonatal death. Out of the total preterm babies born, 59.5% (87/146) were admitted to the nursery. In the study group (2%/3146) were extreme preterm, while 7.5% were severe preterm (11/146). Moderate preterm was 11.6% (17/146) and the majority were late preterm accounting for 78.7% (115/146). Though the incidence of birth asphyxia were noted more in late preterm babies i.e. 10 as the number of these babies are also high in our study but the overall percentage was low (8.7%) as compared with the babies of extreme prematurity (100%) and moderate late prematurity (23.5%) respectively. In pregnancy outcome, 12 were still births in which six (50%) were in the late preterm group. Total of 17 newborns suffered from birth asphyxia in which ten newborns (58.8%) were in late preterm group. Overall, it was noted that the decreasing gestational age was directly correlated to morbidity and mortality. Conclusion: Among the different strata, the late preterm group has been observed to be associated with greater morbidity and mortality. Prior awareness of the morbidities associated with late preterm babies is helpful for the health care providers to anticipate and manage potential complications in preterm infants

Frequency and outcome of meconium aspiration syndrome in babies born with meconium-stained liquor at secondary care hospital in Pakistan: A case series study

Background: Meconium aspiration syndrome (MAS) in the newborn is characterized by hypoxia, hypercapnia, and acidosis. MAS is a leading cause of morbidity and mortality in neonates. The primary objective of this study was to estimate the frequency of meconium aspiration syndrome (MAP) in babies born with meconium-stained liquor. The secondary outcome was to estimate the meconium aspiration syndrome; in terms of hospital stay, complications, and mortality.Methods: The study was done at Aga Khan Maternal and Child Care Centre, Hyderabad, Pakistan. Study design was case series and the duration of the study was of 6 months. All patients who fulfilled the inclusion criteria were included in the study after taking informed written consent. A brief history was taken, clinical examination was done and laboratory investigations were sent to the institutional laboratory. Study outcomes were measured from this data i.e. MAS, its complications, mortality, and a number of days in the hospital.Results: A total of 87 babies born with meconiumstained liquor at secondary care hospital were included. A total of 45 patients (52%) were males and 42 patients (48%) were females with a mean gestational age of babies 38.896 ± 1.210 weeks. The mean Apgar score at 5 minutes was 8.896 ± 0.404. MAS was present in 13 patients (14.9%). Complications were seen only one patient (1.1%) and there was no neonatal death reported.Discussion: MAS was present in 14.9% of babies; the complication of subacute bacterial infection was low seen in just 1.1% cases with no neonatal mortality

Response of extensively drug resistant salmonella typhi to treatment with meropenem and azithromycin, in Pakistan

Introduction: Salmonella Typhi is one of the leading health problems in Pakistan. With the emergence of extensively drug resistant (XDR) Salmonella Typhi, treatment options are limited. Here we report the clinical manifestations and the response to treatment of patients with XDR Typhoid fever. The patients were treated with either Meropenem or Azithromycin or a combination of both.Methods: We reviewed the records of culture confirmed XDR typhoid who visited Aga Khan University Hospital (AKUH), Karachi and Aga Khan Secondary Care Hospital, Hyderabad from April 2017 to June 2018. Symptoms developed during disease, unplanned treatment extension and complications developed while on antimicrobials was recorded. Means with standard deviation were calculated for duration of treatment, time to defervescence, and cost of treatment.Results: Records of 81 culture confirmed XDR typhoid patients admitted at the AKU hospitals were reviewed. Most, (n = 45; 56%) were male. Mean age of the cases was 8.03 years with range (1-40). About three quarter (n = 66) of the patients were treated as inpatient. Fever and vomiting were the most common symptoms at the time of presentation. Oral azithromycin alone (n = 22; 27%), intravenous meropenem alone (n = 20; 25%), or a combination of azithromycin and meropenem (n = 39; 48%) were the options used for treatment. Average (95% confidence interval) time to defervescence was 7.1(5.5-8.6), 6.7(4.7-8.7), and 6.7(5.5-7.9) days for each treatment option respectively whereas there were 1,0 and 3 treatment failures in each treatment option respectively. Average cost of treatment per day for azithromycin was US$5.87 whereas it was US$88.46 for meropenem.Conclusion: Patients treated with either Azithromycin, Meropenem alone or in combination showed similar time to defervescence. Because of the lower cost of azithromycin, it is preferable in lower socio-economic areas. Background estimates for power calculation can be made for more robust clinical trials using this observational data

Ceftriaxone-resistant salmonella typhi outbreak in hyderabad city of sindh, Pakistan: High time for the introduction of typhoid conjugate vaccine

Background: The Aga Khan University clinical microbiology laboratory identified an outbreak of ceftriaxone-resistant Salmonella Typhi in Hyderabad, Pakistan, through antimicrobial resistance surveillance. An outbreak investigation was carried out to identify the risk factors and institute control measures. Here we report the preliminary findings of this outbreak investigation, using data collected from 30 November 2016 to 28 March 2017.Methods: The design for the investigation was a case-control study that included identification of culture-proven ceftriaxone-resistant S. Typhi cases, suspected cases from the households or neighborhood of the confirmed cases, and enrollment of controls matched by age to identify the risk factors. Data were collected through face-to-face interviews using a structured questionnaire. Blood cultures were obtained from all suspected cases. Drinking water samples from each household of cases and controls were obtained for microbiological testing. Geographic Information System coordinates were obtained for all cases and controls.Results: Only 2 subdistricts of Hyderabad (Latifabad and Qasimabad) were affected. A total of 101 confirmed cases of ceftriaxone-resistant S. Typhi had been reported in 4 months with the first case reported on 30 November 2016. Median age was 48 (interquartile range, 29-84) months. The majority (60% [61/101]) of the cases were 6-60 months old. More than half (56% [57/101]) of the cases were male. About 60% of the cases were admitted to hospital and treated as inpatient. More than half (57/101) of the patients developed complications related to typhoid.Conclusions: Community awareness was raised regarding chlorination of drinking water and sanitation measures in Hyderabad. These efforts were coordinated with the municipal water and sewage authority established to improve chlorination at processing plants and operationalize fecal sludge treatment plants. Outbreak investigation and control efforts have continued. Immunization of children with typhoid conjugate vaccine within Hyderabad city is planned