Cardiac involvement in kawasaki disease in Pakistani children

Introduction: Coronary artery involvement is the most dreaded long-term complication of Kawasaki disease. Our aim was to look at the pattern of cardiovascular involvement in Pakistani children admitted with Kawasaki disease.Methods: This study included children admitted with Kawasaki disease at the Aga Khan University Hospital Karachi over a period of 14 years from January 1997 to December 2010. Information gathered included patient demographics, clinical features, investigations, echocardiographic findings, treatment and follow-up. Those with coronary artery involvement on initial echocardiogram remained on long-term follow-up with clinical examination and echocardiogram.Results: A total of 56 patients were admitted. (Mean age at diagnosis 33 ± 30 months, age range 2 months to 9 years). 18% of patients had incomplete features. Twenty-five percent (14/56) patients presented after 10 days of fever. Cardiac examination was normal except for tachycardia. Abnormal coronary arteries were seen in 23 patients (41%) - left main coronary artery in 23 (41%), left anterior descending and right main coronary artery in 20 (36%), circumflex branch in 17 (30%). Risk factors for cardiac involvement were male sex, fever \u3e10 days duration at the time of initial presentation and neutrophil percentage \u3e75% in the initial white blood cell counts. Fifty four of 56 cases received intravenous immunoglobulin (IVIG), Seventy-five percent of the patients received IVIG within 10 days of illness. Mean duration of follow-up was 2.5 years. Eight percent of the patients still continue to have abnormal coronaries. There was no mortality.Conclusions: A higher incidence of coronary artery involvement was found in our study. Presentation after 10 days of illness increases the risk of coronary artery involvement. High index of suspicion among the general pediatricians about the disease can possibly be helpful for early referral and treatment

Acute childhood ischemic stroke: a pakistani tertiary care hospital experience

Stroke in pediatric population is increasingly recognized and has diverse clinical presentation and risk factor profile. Majority of patients survive acute stroke but remain disabled. The reported literature on the subject from our part of world is scarce.Methods:A retrospective chart review was carried out for stroke patients between 1 month and 14 years of age, admitted between January 2009 and January 2015. Their demographic, clinical and radiological data was collected and analyzed.Results:Twenty nine patients were admitted with stroke over 5 years. Their mean age was 5.7 ±11.7 and male to female ratio was 3:1. The most common clinical features reported were seizures (72%), paresis (62%), and altered mental status (52%) followed by fever (38%), cranial nerve palsies (34%) and vomiting (35%). Cardiovascular diseases (28%) were the most common identifiable etiologic factors. Only 59% had unilateral strokes. Fifty five percent had anterior circulation strokes, 14% had posterior circulation strokes while 31% had involvement of both vascular territories. Only 31% had single vessel strokes. Twenty-eight percent of the patient died during the hospital stay (mean stay was 7±5 days). 62% of the infants compared to 18% of older kids (p=0.01), 62% of patients with both vascular territories compared 15% in single territory (p=0.03) and 58% of patients with bilateral strokes compared to 6% in unilateral strokes (p=0.03) died.Conclusions: Cardiovascular diseases are most common etiologic factors of stroke in pediatric age group and it carries high acute mortality. Bilateral and multiple territorial strokes, and age less than one year were associated with acute mortality

Clinical profile and short-term outcome of pediatric hyperleukocytic acute leukemia from a developing country

This study was conducted to determine the frequency, clinical profile, and short-term outcome of children with hyperleukocytosis at two pediatric oncology centers in Karachi. Of a total 1,045 patients, 13.97% (n=146) patients had hyperleukocytosis. Majority (61.7%, n=90) were under 10 years of age and 76% (n=146) were male. The symptom duration before diagnosis was more than 30 days in 49.3% (n=72). The median WBC count was 181 x109/L (IQR=130.45- 298.3) and extreme hyperleukocytosis (\u3e200 x109/L) was observed in 44.5% (n=65) patients. Majority (94.5%, n=138) of patients were diagnosed with acute lymphoblastic leukemia. One or more complications developed in 78% (n=114) of cases. Clinical and laboratory tumor lysis syndrome (TLS) was observed in 17.1% (n=25) and 39% (n=57) patients, respectively. Pulmonary and neurological complications related to leukostasis were noted in 9.5% (n=14) and 27.3% (n=40) of cases, respectively. Infectious complications occurred in 23.2% (n=34) patients. The case-specific mortality was 20.5% (n=30). No mortality was related to early complications of hyperleukocytosis

Congenital factor VII deficiency in children at tertiary health care facility in Pakistan

This study presents the demographics, clinical spectrum, and outcome of patients with congenital factor VII (FVII) deficiency at a tertiary care center over a period of 12 years. Of the 49 patients, 27 (55%) patients were males. Consanguinity was found in 92% of the patients. The median age of symptom onset was 2.4 (interquartile range [IQR]: 1.1-6.5) years with a median age of 5.8 (IQR: 3.1-10) years at diagnosis. Life-threatening complications like intracranial bleeding (ICB) and intra-abdominal bleeding (IAB) were observed in 8 (16.4%) patients. We found that 11 (55%) of the 20 patients with FVII coagulant activity (FVIIc) 5% were affected by severe symptoms. Age (P = .042; odds ratio 6.46). Overall, 4 (8.2%) died as a consequence of ICB (3 patients) and IAB (1 patient)

Neonatal sepsis following prolonged rupture of membranes in a tertiary care hospital in Karachi, Pakistan

Introduction: Prolonged rupture of membrane (PROM) is an important risk factor for early onset neonatal sepsis (EONS), which is associated with increased neonatal morbidity and mortality. We reported the incidence and associated risk factors of PROM for culture-proven EONS. Methodology: The medical records of all neonates born at Aga Khan University, Karachi over a period of five years (2007-2011) with PROM (\u3e 18 hours) were reviewed. Data about maternal and neonatal risk factors for EONS was collected and adjusted logistic regression (AOR) analysis was applied. Results: Incidence of PROM in this neonatal birth cohort was 27/1,000 live births. A total of 17 (4%) cases with blood-culture proven bacterial sepsis were identified within 72 hours of birth. Klebsiella pneumonia (n = 5; 29%) and Pseudomonas aeruginosa (n = 4; 24%) were the commonest isolates followed by group B Streptococcus (n = 3; 18%) and Escherichia coli (n = 2; 12%). Maternal fever (p = 48 hr. (p \u3c 0.001; AOR, 8.2), neonatal prematurity \u3c 34 weeks (p \u3c 0.001; AOR, 4.1) and low birth weight \u3c 1,500 grams (p 0.001; AOR, 9.8) along with neonatal thrombocytopenia and raised CRP were found to be independent risk factors associated with culture-proven EONS in PROM. Conclusions: Preventive measures should focus on recognition of these high-risk infants with prompt laboratory screening for sepsis and early institution of empirical antibiotic based on local data. Such approaches would be a safe and cost-effective strategy, especially in developing countries

Anthracycline-induced cardiotoxicity: prospective cohort study from Pakistan

Objectives: To identify anthracycline-induced acute (within 1 month) and early-onset chronic progressive (within 1 year) cardiotoxicity in children younger than 16 years of age with childhood malignancies at a tertiary care centre of Pakistan. Design: Prospective cohort study. Setting: Aga Khan University, Karachi, Pakistan. Participants: 110 children (aged 1 month–16 years). Intervention: Anthracycline (doxorubicin and/or daunorubicin). Outcome measurements: All children who received anthracycline as chemotherapy and three echocardiographic evaluations (baseline, 1 month and 1 year) between July 2010 and June 2012 were prospectively analysed for cardiac dysfunction. Statistical analysis including systolic and diastolic functions at baseline, 1 month and 1 year was carried out by repeated measures analysis of variance. Results: Mean age was 74±44 months and 75 (68.2%) were males. Acute lymphoblastic leukaemia was seen in 70 (64%) patients. Doxorubicin alone was used in 59 (54%) and combination therapy was used in 35 (32%). A cumulative dose of anthracycline /m2was used in 95 (86%). Fifteen (14%) children developed cardiac dysfunction within a month and 28 (25%) children within a year. Of these 10/15 (66.6%) and 12/28 (43%) had isolated diastolic dysfunction, respectively, while 5/15 (33.3%) and 16/28 (57%) had combined systolic and diastolic dysfunction. Seven (6.4%) patients expired due to severe cardiac dysfunction. Eight of 59 (13.5%) children showed dose-related cardiotoxicity (p= Conclusions: Incidence of anthracycline-induced cardiotoxicity is high. Long-term follow-up is essential to diagnose its late manifestations

Hematopoietic stem cell transplantation in children with hemoglobinopathies: A single-center experience

INTRODUCTION: Hematopoietic stem cell transplantation (HSCT) is a curative treatment for children with serious hematological disorders including thalassemia major (TM) and sickle cell disease (SCD). This study aimed to determine the frequencies of transplant-related morbidity and outcome in our tertiary health-care facility. MATERIALS AND METHODS: We retrospectively analyzed the clinical, laboratory, and outcome data of 32 cases of hemoglobinopathies (TM = 19 and SCD = 13) who underwent bone marrow (BM) transplantation between 2005 and 2016. SPSS was used for statistical analysis, and Kaplan–Meier curve was constructed for overall survival (OS) and event-free survival. RESULTS: The median age of the study population at the time of transplant was 7.8 (range 2–14 years). Male-to-female ratio was 1:1. All patients were received allogeneic full matched related donor transplantation. Conditioning regimen was Bu/Cy/antithymocyte globulin (ATG) for SCD and Flu/Bu/Cy/ATG for TM. Source of stem cell in all patients was bone marrow and median stem cell dose CD 34+ was 5.26 (range 2.9–9.9) × 106/kg. All patients were received cyclosporin and methotrexate for graft versus host disease (GVHD) prophylaxis. Acute and chronic GVHD were observed in 10 (31.25%) and 2 (6.3%) cases, respectively. The median time to absolute neutrophil count (ANC) engraftment was 22 days (range: 12–27), and the median time to platelet engraftment was 32 days (range: 18–45) in 28 patients and the remaining four patients had delayed platelet engraftment (62–90 days). Cytomegalovirus (CMV) reactivation was observed in 18 (56.3%) cases; majority were asymptomatic (n = 17/18; 94.4%). Three-year event-free survival (EFS) and OS were 90.6% and 93.7%, respectively, with median duration of follow-up 33.72 (± 25.3) months. CONCLUSION: The results of the pediatric HSCT for hemoglobinopathies at our institution are excellent and are comparable to published reports from international collaborative groups

Risk factors for complicated varicella infection in pediatric oncology patients at a tertiary health care facility in Pakistan

Introduction: Varicella zoster infection (VZI) is well recognized as a potential cause of morbidity and mortality in immunocompromised pediatric oncology patients (POP). The purpose of this study was to describe the clinical profile and risk factors for complications and outcomes of VZI in POP treated with acyclovir.METHODOLOGY: Medical records of all POP with a discharge diagnosis of VZI over a period of seven years (2005-2011) were reviewed. The demographic features, underlying malignancy, risk factors for VZI, complications, and outcomes were recorded.Results: Thirty-six POP with VZI were identified. Leukemia was the most common underlying malignancy (n = 20, 58.8%), followed by lymphoma (n = 7, 20.6%) and solid organ tumors (n = 7, 20.6%). Most of the cases (41%) were observed in children under five. All patients were treated with acyclovir. Varicella-related complications developed in 10 (29%) patients. The most frequent complication was bloodstream infection (n = 3, 8.8%), followed by pneumonia (n = 2, 5.9%), skin infection (n = 2, 5.9%), hepatitis, renal failure, and encephalitis. Independent risk factors associated with complications were age \u3c five years, weight for age \u3c fifth percentile, delay in seeking care (\u3e seven days after onset of symptoms) and severe neutropenia (ANC \u3c 500/cm). One child died secondary to varicella encephalitis.CONCLUSION: Our data suggests that young age, poor health-seeking behavior, severe neutropenia, and being underweight are the major risk factors for the development of varicella-related complications in POP in developing countries. These complications could be favorably modified through active immunization of immunocompetent children

An Investigation of Credit Card Default Prediction in the Imbalanced Datasets

Financial threats are displaying a trend about the credit risk of commercial banks as the incredible improvement in the financial industry has arisen. In this way, one of the biggest threats faces by commercial banks is the risk prediction of credit clients. Recent studies mostly focus on enhancing the classifier performance for credit card default prediction rather than an interpretable model. In classification problems, an imbalanced dataset is also crucial to improve the performance of the model because most of the cases lied in one class, and only a few examples are in other categories. Traditional statistical approaches are not suitable to deal with imbalanced data. In this study, a model is developed for credit default prediction by employing various credit-related datasets. There is often a significant difference between the minimum and maximum values in different features, so Min-Max normalization is used to scale the features within one range. Data level resampling techniques are employed to overcome the problem of the data imbalance. Various undersampling and oversampling methods are used to resolve the issue of class imbalance. Different machine learning models are also employed to obtain efficient results. We developed the hypothesis of whether developed models using different machine learning techniques are significantly the same or different and whether resampling techniques significantly improves the performance of the proposed models. One-way Analysis of Variance is a hypothesis-testing technique, used to test the significance of the results. The split method is utilized to validate the results in which data has split into training and test sets. The results on imbalanced datasets show the accuracy of 66.9% on Taiwan clients credit dataset, 70.7% on South German clients credit dataset, and 65% on Belgium clients credit dataset. Conversely, the results using our proposed methods significantly improve the accuracy of 89% on Taiwan clients credit datase..