Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications

Background

The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines.

Methods

Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set.

Results

Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males.

Conclusions

This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly.

Improvement of Left Ventricular Systolic Function after Percutaneous Coronary Intervention in Diabetic Patients with Non-ST elevated Myocardial Infarction

Long term mortality is higher in Non-ST-segment elevated myocardial infarction (NSTEMI) patients than STEMI paitents. NSTEMI are a high risk factor for ensuing cardiovascular events in diabetic patients. But, use of drug eluting stents (DES) will further improve outcomes in patients with diabetes suffering early percutaneous coronary intervention (PCI). The aim of the study was to determine the changes in left ventricular (LV) systolic activity after successful PCI in NSTEMI diabetic patients was compared with non-diabetic patients. This comparative clinical study was performed in the Department of Cardiology, University Cardiac Center, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2017 to June 2018. Thirty (30) diabetic and 34 non-diabetic patients with NSTEMI undergoing percutaneous coronary intervention were included in the study. In all patients PCI with drug eluting stent was performed successfully. Earlier echocardiography (2-Dimensional) was done, at release subsequent PCI and 3 months afterward to evaluate the LV systolic activity and compare to diabetics and non-diabetics at all levels of evaluation to assess the outcome of intervention. At baseline LVEF was rather lower in diabetic group than non-diabetic group patients. In diabetics patients segments with abnormal wall motion (WMA) was higher than non-diabetics patients. While the LVEDD, LVIDd and LVIDs were significantly larger in the earlier group than those in the latter group, the LVESV was no different in both groups. At release from hospital, no significant enhancement was observed in either group following PCI in terms of LVEF, number of segments with WMA, LVIDd and LVIDs. However, both LVEDV and LVESV reduced successfully in both groups with decrease of LVESV being more marked in non-diabetics compared with diabetics (p=0.018). However, 3 months after PCI, LVEF improved (8.4±1.2%) in diabetics and 7.9±1.2% in non diabetics patients but this improvement between two groups was not statically significant (p=0.631). Similarly baseline to 3 months after PCI LVIDs reduces in diabetics patients (5.7±1.9%) and 4.8±1.1% in non diabetics patients but the difference between both groups was not significant (p=0.201). Diabetic patients more frequently required 2 stents (p=0.30), while stent's diameter and length did not differ between the study groups. This study demonstrated that improvement of the parameters of left ventricular systolic function after using of drug eluting stent in NSTEMI diabetic patients was not lower to the non diabetic group under same condition. So, suggestion of PCI with drug eluting stent may be extended in NSTEMI diabetic patient.

Comparison between Glyceryl Trinitrate and Trimetazidine in Ischaemic Cardiomyopathy Patients

Ischaemic cardiomyopathy (ICM) remains a major health problem, both in developed and developing countries like Bangladesh where it causes a significant number of morbidity and mortality. The treatment and outcome of ICM chiefly depends on the presence and extent of hibernating myocardium. In this regard addressing anginal symptoms is the key to patients' comfort as well to achieving the goal of treatment. Glyceryl trinitrate (GTN) and trimetazidine (TMZ) are two widely used drugs for relieving angina. This pilot study was designed to answer some of the confusions and controversies regarding their use and to bring precision in decision making in the treatment of ICM. Here, comparison of GTN and trimetazidine were done by assessing the symptoms by NYHA and CCS class following their use in ICM patients, admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 15th October, 2015 to 15th April, 2016, who were randomly placed in two groups in a prospective manner. Most of the patients were in age group 51-60 years and were male in both the groups. It was observed that there was no significant difference in NYHA and CCS class at base line and at discharge between two groups (p>0.05). But statistically significant (p<0.05), improvement noted at 6 weeks and 12 weeks in GTN group in comparison to trimetazidine group. GTN stood out to be a better option than TMZ in the treatment of ICM. Moreover GTN is a cheaper option than TMZ.

Frequency, Distribution of Congenital Anomaly and Associated Maternal Risk Factors

This study was done to find out the maternal risk factors associated with congenital anomaly. This cross-sectional observational study was carried out in the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital, Dhaka, Bangladesh from January 2011 to December 2011. During this study period 78 patients had pregnancy with congenital anomaly and delivered in the Department of Obstetrics and Gynaecology. Women with ultrasound report of congenitally abnormal fetus irrespective of gestational age were included. Clinical evaluation of neonates was done by experienced neonatologist. The frequency of congenital anomaly was 3.46%. Most of the women belong to age <35 years (97.43%). Congenital anomalies more commonly were seen in the primiparas (64.10%). Most frequent associated risk factor was the history of abortions (35.89%). Maternal infections during antenatal period were also high (15.58%). There were 58 males (74.35%) and 20 females (25.64%). There was positive history of delivery of congenital abnormal babies in 6 cases (7.6%). Mothers of eight cases (10.25%) had history of drug ingestion during pregnancy. Four cases (5.12%) of mothers had hypothyroidism and 6 cases of mothers (7.69%) had diabetes mellitus respectively.

A Case Report on Percutaneous Coronary Intervention in Chronic Total Occlusion by Retrograde Visualization

As bilateral approach is paramount in chronic total occlusions with retrograde flow, the use of two radial arteries, two femoral arteries or combination technique using one radial and one femoral artery will probably be increasingly reported in the near future. After puncture of opposite groin, a diagnostic 6 Fr catheter is used to intubate the ostium of the contralateral artery. By visualizing the distal vessel in multiple projections, contralateral injections help to direct the progression of the wire in the occluded segment towards the distal true lumen and confirm the intraluminal position of the wire after the occluded segment. We are reporting a case with chronic total occlusion where we used bilateral femoral access and simultaneous contrast injection to visualize retrograde flow in LAD while opening CTO through ante-grade pathway.

Pattern of congenital heart diseases

This prospective observational study was done to find out the frequency of various forms of congenital heart disease (CHD) diagnosed by echocardiography. During the study period (January 2002 to December 2005) 2050 patients were screened by echocardiography. All patients were evaluated by cardiologists and had chest radiograph, electrocardiogram and echocardiography. Total 2050 patients were studied and among them 1071 had congenital heart disease. Male was 561(52.38%) and female was 510(47.62%). Atrial septal defect (ASD) was 374(34.92%), ventricular septal defect (VSD) was 318(29.69%), patent ductus arteriosus (PDA) 83(7.75%), pulmonary stenosis (PS) 58(5.42%), tetralogy of Fallot 162(15.13%), transposition of great vessels (TGA) 16(1.49%), Ebstein anomaly 5(0.4%), coarctation of aorta 1(0.09%) and single ventricle 2(0.19%). This distribution is more or less similar to that reported in studies at home and abroad. In this study atrial septal defect (ASD) was the commonest in acyanotic CHD and tetralogy of Fallot was the commonest cyanotic CHD.

Effect of hydration with or without n-acetylcysteine on contrast induced nephropathy in patients undergoing coronary angiography and percutaneous coronary intervention

Contrast induced nephropathy (CIN), an acute decline in renal function after the administration of intravenous contrast in the absence of other causes, is the third leading cause of acute renal failure in hospitalized patients. Antioxidant N-acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who underwent coronary angiography (CAG) and percutaneous coronary intervention (PCI). Hydration is the cornerstone in preventing CIN. N-acetylcysteine has additive preventive affect. We compared N-acetylcysteine plus hydration with hydration alone in preventing CIN. Patients were assigned to receive either premedication with hydration with normal saline (1ml/kg/hour-12 hour before and 12 hour after CAG and intravenous PCI) alone or to receive both hydration and oral N acetylcysteine (600mg bid for 2 days, starting day before CAG and PCI). Main out come was occurrence of ≥25% or ≥0.5mg/dl increase in serum creatinine level within 24 to 48 hours after contrast administration; change in creatinine clearance and serum creatinine level. Six patients (12%) of hydration group i.e. Group A and none of the patients of N-acetylcysteine All group i.e. Group B develop CIN (p=0.012). Baseline serum creatinine level was slightly higher in N-acetylcysteine group than hydration group (1.52±0.32 and 1.44±0.22). After 24 hours of CAG and PCI serum creatinine level lower than base line in N-acetylcysteine group but slightly higher than base line in hydration group (1.42±0.39 and 1.51±0.38). Difference in serum creatinine in both the groups were statistically significant (p=0.006 in N-acetylcysteine group and p=0.029 in hydration group). Creatinine clearance rate significantly improved in N-acetylcysteine group after coronary intervention. In conclusion, N-acetylcysteine and hydration prevent CIN better than hydration alone in high risk patients.

Contrast induced nephropathy in patients with pre-existing renal impairment undergoing coronary angiogram and percutaneous transluminal coronary angioplasty

Contrast induced nephropathy is the third leading cause of acute renal failure in hospitalized patients. However, its incidence and risk factors in Bangladeshi population undergoing coronary angiogram and percutaneous coronary intervention is not clear. This study was to assess the incidence of contrast induced nephropathy in patients, with or without pre existing renal impairment, undergoing coronary angiogram and percutaneous transluminal coronary angioplasty in Bangladeshi population. Two hundred patients undergoing coronary angiogram and percutaneous were included in the study .Patients having history of contrast allergy and patients on renal dialysis were excluded from the study. Serum creatinine level was estimated before the undergoing procedure. Creatinine clearance rate was calculated by applying Cockcroft Gault formula to the preprocedure serum creatinine level. Patients were assigned to one of the two groups, that is with or without chronic renal insufficiency. Serum creatinine levels were again estimated at the end of 24 hours of contrast exposure. The rise of serum creatinine by ≥0.5mg/dl or ≥25% occurring within 24 hours of contrast administration was defined as contrast induced nephropathy. The incidences of Contrast induced nephropathy (CIN) in these groups were compared. We tried to analyze whether there is relation between the incidence of CIN with contrast volume, chronic renal insufficiency, diabetes mellitus, and coronary procedures undergone. We enrolled 120 pre existing chronic renal insufficiency patients and 80 patients without pre existing chronic renal insufficiency. In this study 21.7% of pre existing chronic renal insufficiency group and 6.3% of no pre existing chronic renal insufficiency group developed contrast induced nephropathy (p=0.003). Contrast induced nephropathy is an iatrogenic disorder and pre existing renal impairment is one of the risk factors for developing contrast induced nephropathy.

Association of cardiac ischemic score and coronary collateral circulation

Coronary collateral circulation maintains myocardial perfusion in coronary atherosclerotic disease. The indicators of cardiac ischemia, (Angina pectoris on exertion, during emotion, previous myocardial infarction and prior coronary intervention) are associated with presence of coronary collateral circulation. In this prospective observational cross sectional study, 128 patients with history of angina pectoris on exertion and or during emotion and or myocardial infarction and or previous coronary intervention were enrolled. The cardiac ischemic score (range 1-4) was calculated by adding 1 point for each of the above four clinical factors, which can be easily assessed. Presence of coronary collaterals in coronary angiogram was defined as Rentrop grade ≥1. Patients were divided into two groups. Group A patients having Rentrop grade 0 and Group B patients are with collateral circulation, having Rentrop grade 1-3. Patients having cardiac ischemic score (range 1-4) are compared in these groups. Maximum (83.3%) patients of Group B with coronary collateral circulation had cardiac ischemic score 2-4, but majority (86.4%) of Group A patients without collaterals showed the score only 1. Thus the cardiac ischemic score is strongly associated with the presence of coronary collaterals.

Microbes responsible for acute exacerbation of COPD

This study was designed to find out the microbes responsible for acute exacerbation of chronic obstructive pulmonary disease (COPD). This study was carried out in the National Institute of Diseases of the Chest & Hospital (NIDCH), Dhaka during the period of January 2003 to December 2003. The study was a prospective case control study. There were 88 male and 2 female patients. The majority of the study subjects fell within the range of 50-70 years. All were smokers. 30 stable COPD patients were taken as control for comparison of sputum culture results of acute exacerbated COPD patients. A standard proforma with questionnaire was designed and filled to select patient with COPD. The patients were selected according to the predetermined criteria viz FEV1<70% predicted and FEV1/FVC % <70% of predicted. Morning specimen of sputum was collected after appropriate preparation and physical character of the sputum were noted. Sputum was immediately sent to microbiology lab for culture. Out of 30 stable COPD patients 6(20%) showed positive sputum culture for bacteria, Pseudomonas 3, Klebsiella 1, Streptococcus pneumoniae 1 and Haemophilus influenza 1. Majority of them were Gram-negative organism. Out of 60 patients with acute exacerbation of COPD 39 patients (65%) showed positive culture for bacteria. Pseudomonas 15, Klebsiella 8, Acinetobacter 4, Enterobacter 2, Moraxella catarrhalis 2 and mixed organisms like, Pseudomonas + Klebsiella 2 and Pseudononas + Acinobacter 1. Majority were Gram-negative bacilli viz. Pseudomonas and Klebsiella spp. species. From this study it was concluded that the prevalence of lower airway bacterial colonization in outpatients with stable COPD is high and is mainly due to Gram-negative bacilli like Pseudomonas spp. The greater rate of isolation of pathogenic bacteria in exacerbated COPD than in stable COPD in this study, supports the pathogenic role of bacteria in a proportion of acute exacerbations of chronic obstructive pulmonary disease. The organism commonly play pathogenic role in acute exacerbations of COPD are Pseudomonas and Klebsiella. Acinobacter Moraxella catarrhalis and Enterobacter also contributed in exacerbation of COPD.

Haemodynamic and end tidal CO2 changes state after inflation and deflation of pneumatic tourniquet on extremities

The use of a tourniquet for obtaining a bloodless field is an essential and accepted tool for extremity surgery. A prospective study was done on 30 adult patients undergoing elective limb surgery requiring tourniquet application for haemodynamic and End tidal CO2 (EtCO2) changes. After the induction of general anaesthesia a tourniquet was applied on the limb. There was gradual increase in heart rate & EtCO2 through out the whole period of tourniquet inflation. There was also significant increase of mean arterial pressure during the inflation period. At the end of surgery tourniquet was deflated. Tourniquet time was 76.83+/-16.94 minutes. After deflation of the tourniquet, heart rate & EtCO2 value increased & the values were maximum at 5 minutes. These values came down to the base line at 15 minutes. There was significant decrease of mean arterial pressure (MAP) at 5 minute; it also came to the base at 15 minute. These changes are usually benign but can be significant in patients with co-existing cardiovascular & intracranial diseases. In conclusion, we recommend the haemodynamic and End tidal CO2 monitoring as well as rapid fluid infusion along with hyperventilation for 15-30 minutes after deflation of tourniquet.

Proximal aneurysms in association with arteriovenous malformations: do they resolve following obliteration of the malformation with stereotactic radiosurgery?

One-hundred consecutive patients were identified who had arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (STRS) which were totally obliterated as shown by follow-up angiography. Of these cases, seven had intracerebral aneurysms at initial angiography, two of which were multiple. Five patients had saccular aneurysms at commonly recognized sites on the circle of Willis or main proximal cerebral arteries, while two patients had aneurysms on distal AVM feeder arteries in atypical sites (one saccular, one fusiform). Saccular aneurysms at typical sites were found to be unchanged in size following AVM obliteration. The significance of this finding in the management of patients who present with subarachnoid haemorrhage and who have both aneurysms and AVMs is discussed.

The pharmacokinetics and UK usage of heparin in vascular intervention

Intravascular heparin is used routinely during peripheral and visceral angioplasty, although usage and dose vary widely. The aims of this prospective study were to: (1) Determine the pattern of Heparin usage by Vascular/Interventional Radiologists in the UK. (2) Determine the optimum doses of Heparin for vascular intervention on the basis of its pharmacokinetic profile. A questionnaire was sent to Consultant Radiologists who were also members of the British Society of Interventional Radiology (BSIR), regarding their use of heparin during peripheral angioplasty. This included heparin doses in flushing solution, timing and amounts of heparin used as a bolus dose and monitoring of clotting times. Seventy-three percent returned completed forms. A wide variation in practice was shown. Apart from the variety of individual protocols in use, significant findings were that more than 75% of the respondents were giving heparin as a bolus only after the lesion had been crossed with a guide-wire. None of the respondents were monitoring clotting times, even in prolonged and complicated procedures. The pharmacokinetic profiles of two separate bolus doses of heparin in two groups of 30 and 25 patients each were then evaluated. Our results showed that a 3000 IU bolus of heparin maintained the plasma APTT in the therapeutic range (at least twice the normal value), for at least 30 min in the majority of patients. A 5000 IU bolus maintained the APTT in the therapeutic range for 45 min in the vast majority of patients. Apart from minor bruising at the compression site and slightly increased compression times in a small number of patients, no significant immediate complication was noted. We conclude that in the context of peripheral angioplasty, there is a wide variation in the use of heparin as an adjunct to the procedure. In the light of our own experience we recommend a 3000 IU intra-arterial bolus of unfractionated heparin to be given once arterial access has been achieved. This would cover short, uncomplicated procedures. The larger 5000 IU dose would be more appropriate for longer and more complicated procedures. We also recommend monitoring APTT values in prolonged procedures, with administration of further bolus doses of heparin if required.