Heated and humidified high flow therapy (HHHFT) in extreme and very preterm neonates with respiratory distress syndrome (RDS): a retrospective cohort from a tertiary care setting in Pakistan

OBJECTIVE

To determine the role of heated humidified high flow therapy (HHHFT) as primary respiratory support in spontaneously breathing moderate-late, very and extreme preterm neonates with respiratory distress syndrome (RDS) at a tertiary care hospital from a developing country.

DESIGN

Retrospective cohort study.

SETTING

Neonatal intensive care unit of Indus Hospital and Health Network, Karachi, Pakistan.

PATIENTS

All preterm neonates with RDS and who received HHHFT as primary respiratory support were included retrospectively, while neonates with orofacial anomalies, congenital heart and lung diseases other than RDS, abdominal wall defects, encephalopathy, congenital pneumonia and received continuous positive airway pressure or invasive ventilation were excluded.

INTERVENTIONS

HHHFT as primary respiratory support for RDS.

MAIN OUTCOME MEASURES

Effectiveness, duration, failure rate and complications of HHHFT as a primary respiratory support in moderate-late, very and extremely preterm neonates were evaluated.

RESULTS

The cohort included 138 neonates during a period of 12 months. The median gestational age was 32 weeks, and the median birth weight was 1607 g. Grade 1-2 RDS was seen in 97%, surfactant instillation was done in 10.8% and HHHFT was provided in all the neonates as primary respiratory support. The total duration of HHHFT support was <1 week in 94% of neonates. Bronchopulmonary dysplasia and pneumothorax until discharge or death were observed in one neonate, haemodynamically significant Patent Ductus Artriosus (HsPDA) in two neonates and intraventricular haemorrhage Grade ≥2 in five neonates, while only one neonate died.

CONCLUSION

This study appears to show that HHHFT is a simple, safe, efficient and cheap mode of primary respiratory support that can be given to spontaneously breathing moderate-late, very and extremely preterm neonates with RDS, especially in low- or middle-income countries.

Electronic reporting of rare endocrine conditions within a clinical network: results from the EuRRECa project

Objective

The European Registries for Rare Endocrine Conditions (EuRRECa, eurreb.eu) includes an e-reporting registry (e-REC) used to perform surveillance of conditions within the European Reference Network (ERN) for rare endocrine conditions (Endo-ERN). The aim of this study was to report the experience of e-REC over the 3.5 years since its launch in 2018.

Methods

Electronic reporting capturing new encounters of Endo-ERN conditions was performed monthly through a bespoke platform by clinicians registered to participate in e-REC from July 2018 to December 2021.

Results

The number of centres reporting on e-REC increased to a total of 61 centres from 22 countries. A median of 29 (range 11, 45) paediatric and 32 (14, 51) adult centres had reported cases monthly. A total of 9715 and 4243 new cases were reported in adults (age ≥18 years) and children, respectively. In children, sex development conditions comprised 40% of all reported conditions and transgender cases were most frequently reported, comprising 58% of sex development conditions. The median number of sex development cases reported per centre per month was 0.6 (0, 38). Amongst adults, pituitary conditions comprised 44% of reported conditions and pituitary adenomas (69% of cases) were most commonly reported. The median number of pituitary cases reported per centre per month was 4 (0.4, 33).

Conclusions

e-REC has gained increasing acceptability over the last 3.5 years for capturing brief information on new encounters of rare conditions and shows wide variations in the rate of presentation of these conditions to centres within a reference network. Significance statement Endocrinology includes a very wide range of rare conditions and their occurrence is often difficult to measure. By using an electronic platform that allowed monthly reporting of new clinical encounters of several rare endocrine conditions within a defined network that consisted of several reference centres in Europe, the EuRRECa project shows that a programme of e-surveillance is feasible and acceptable. The data that have been collected by the e-reporting of rare endocrine conditions (e-REC) can allow the continuous monitoring of rare conditions and may be used for clinical benchmarking, designing new studies or recruiting to clinical trials.

Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country

OBJECTIVE

Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes.

DESIGN

This was a quality improvement initiative. Data were collected retrospectively before and after the intervention.

SETTING

A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan.

PATIENTS

All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018.

INTERVENTIONS

A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU.

MAIN OUTCOME MEASURES

We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay.

RESULTS

Neonates on SPN had greater rate of change in weight compared with IPN (β=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group.

CONCLUSIONS

We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.

Accuracy of Spontaneous Breathing Trial Using ET-CPAP in Predicting Successful Extubation of Neonates

Objective: Extubation failure is common in mechanically ventilated neonates. Finding objective criteria for predicting successful extubation may help to reduce the incidence of failure and the length of mechanical ventilation (MV). We conducted this study to determine the accuracy of the spontaneous breathing trial (SBT) and lung function measurements in predicting successful extubation in neonates. Methodology: This cross-sectional validation study was conducted at a tertiary care neonatal intensive care unit (NICU) over 12 months from December 2019 to December 2020. Neonates intubated for >24 hours and considered ready for extubation were enrolled in the study. Neonates who met defined eligibility criteria underwent a three minutes SBT using endotracheal continuous positive airway pressure (ET-CPAP) before extubation. The primary clinical team was blinded to the results, and all neonates were extubated after SBT. Extubation was considered successful if patients remained extubated for 48 hours.

Results: Among the 107 infants, 77.5% (n=83) of infants passed the SBT. Of these, 78 were successfully extubated, giving the positive predictive value of 93.97%. The overall extubation success rate was 90% (n=96). The sensitivity and specificity of SBT were 81.2% and 54.5%, respectively. VE (ET-CPAP) and VE-ventilator at a cutoff of ≥238 ml and ≥143.7 ml have an area under the curve (AUC) of 0.77 and 0.75 respectively to predict successful extubation (p-value 0.003, 0.008 respectively). Conclusion: SBT predicts extubation success with pronounced accuracy. Therefore, we propose SBT as a valuable and crucial step that guides clinicians' decision-making regarding extubation preparedness or impending failure in neonates.

A Case of Early Diagnosis of Turner Syndrome in a Neonate

Turner syndrome (TS), or Bonnevie-Ullrich syndrome, also known as congenital ovarian hypoplasia syndrome, is the most common sex chromosome abnormality in females in approximately 1 in 2000 live birth. It occurs when the X chromosome is partially or completely missing in females caused by monosomy or structural abnormalities of the X chromosome. It is mainly diagnosed in late childhood or adolescent age and rarely identified during the neonatal period. It is characterized by short stature, webbed neck, lymphedema of extremities, widely spaced-out nipples, and cubital valgus. Early diagnosis of TS allows for appropriate and timely initiation of therapy with comprehensive care. We report a case of a neonate presented with the complaint of edema of feet since birth and syndromic features. TS was diagnosed by the chromosomal analysis, which demonstrated a gene karyotype of 46.X,i(X)(q10){20}.

Variation in Oxygen Saturation by Pulse Oximetry During and After Breastfeeding Among Healthy Term Neonates During Early Postnatal Life at Tertiary Care Hospital

Background

Breastfeeding plays a vital role in a newborn’s life as it increases its chances of survival and is considered the optimal nutritional source for newborns. All newborns must have developed the suck, swallow, and breathe coordination in order to safely breastfeed. Studies conducted on breastfeeding in healthy term babies are limited as most studies available on breastfeeding focus on preterm babies. Full-term healthy infants can also present with feeding difficulties but due to a lack of studies conducted on them, there is no existing oxygen saturation pattern for healthy term infants. Thus, our study is designed to observe variations in the oxygen saturation of healthy term infants during breastfeeding.

Methodology

A cross-sectional study was conducted in a tertiary care hospital from March 2021 to April 2021. Using a non-probability consecutive sampling technique, 60 neonates were enrolled in the study. The baby was monitored for heart rate and oxygen saturation before, during, and after feeding.

Results

The oxygen saturation levels were lower during feed while it was significantly high after a feed (p < 0.001). No significant variation was seen between saturation before feeding and during feed (0.635) or before feeding with after feed (p = 0.108). Maximum oxygen saturation drop was observed in 21% at the first minute and cumulatively 73% of neonates within the first five minutes of feeding. Heart rate remained in the physiological range (120-160 b/min) in 85%, above 160 in just 11.6% of the babies.

Conclusion

Effective breastfeeding is crucial for the growth and development of every infant, which is why there is a need to have an understanding of how infants develop suck, swallow, and breathe coordination. Having breathing and sucking patterns for infants can help medical personal identify when an infant is having difficulty with oral feeding and suggest safer, more effective methods of breastfeeding.

A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan

Introduction

Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness.

Methodology

A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed.

Results

The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied.

Conclusion

Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.

Nasal High Frequency Oscillatory Ventilation (nHFOV): Rescue Treatment for Respiratory Distress Syndrome in Preterm Infants

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Supporting international networks through platforms for standardised data collection-the European Registries for Rare Endocrine Conditions (EuRRECa) model

Rare endocrine pathology is manifested by either a deficiency or excess of one or more hormones. These conditions can be life-threatening and are almost universally associated with long-term morbidity. Understanding the aetiology of these conditions requires multicentre collaboration and expertise, most often across national boundaries, with the capacity for long-term follow-up. The EuRRECa (European Registries for Rare Endocrine Conditions) project ( www.eurreca.net ), funded by the EU Health Programme, aims to support the needs of the wider endocrine community by maximising the opportunity for collaboration between patients, health care professionals and researchers across Europe and beyond. At the heart of the EuRRECa collaboration is a Core Endocrine Registry that collects a core dataset for all rare endocrine conditions that are covered within Endo-ERN. The registry incorporates patient reported markers of clinical outcome and will signpost participants to high-quality, disease-specific registries. Furthermore, an electronic surveillance programme (e-REC) captures clinical activity and epidemiology for these rare conditions. EuRRECa receives guidance compliant with the highest ethical standards from Expert Working Groups that align with the Main Thematic Groups of Endo-ERN. Security, data quality and data governance are cornerstones of this platform. Clear policies that are acceptable to patients, researchers and industry for data governance coupled with widespread dissemination and knowledge exchange through closely affiliated stakeholders will ensure sustainability beyond the current lifetime of the project. This paper describes the infrastructure that has been developed, stakeholder involvement, the data fields that are captured within the registry and details on the process for using the platform.

Vertical Transmission of Novel Coronavirus (COVID-19) from Mother to Newborn: Experience from a Maternity Unit, The Indus Hospital, Karachi

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Personal protective equipment for surgeons during COVID-19 pandemic: systematic review of availability, usage and rationing

BACKGROUND

Surgeons need guidance regarding appropriate personal protective equipment (PPE) during the COVID-19 pandemic based on scientific evidence rather than availability. The aim of this article is to inform surgeons of appropriate PPE requirements, and to discuss usage, availability, rationing and future solutions.

METHODS

A systematic review was undertaken in accordance with PRISMA guidelines using MEDLINE, Embase and WHO COVID-19 databases. Newspaper and internet article sources were identified using Nexis. The search was complemented by bibliographic secondary linkage. The findings were analysed alongside guidelines from the WHO, Public Health England, the Royal College of Surgeons and specialty associations.

RESULTS

Of a total 1329 articles identified, 95 studies met the inclusion criteria. Recommendations made by the WHO regarding the use of PPE in the COVID-19 pandemic have evolved alongside emerging evidence. Medical resources including PPE have been rapidly overwhelmed. There has been a global effort to overcome this by combining the most effective use of existing PPE with innovative strategies to produce more. Practical advice on all aspects of PPE is detailed in this systematic review.

CONCLUSION

Although there is a need to balance limited supplies with staff and patient safety, this should not leave surgeons treating patients with inadequate PPE.

Aniridia: A Rare Manifestation Of Congenital Rubella Syndrome

A foetus affected by a congenital rubella infection can develop congenital rubella syndrome (CRS). Aniridia is the absence of iris, rarely been described in literature in association with CRS, can easily be overlooked, leading to complications e.g. glaucoma and blindness later in life. We report a case of a neonate with CRS and aniridia presenting at a tertiary care hospital.

Quality improvement initiative using transcutaneous bilirubin nomogram to decrease serum bilirubin sampling in low-risk babies

BACKGROUND

Screening for neonatal hyperbilirubinaemia in the postnatal ward has traditionally been performed using serum bilirubin sampling, but this has significant drawbacks such as risk of infection and slower reporting time.

OBJECTIVE

We aimed to assess the impact of introducing transcutaneous bilirubin (TcBR) testing using TcBR nomogram on the number of serum bilirubin samples sent.

METHODS

A before-and-after study was performed following the introduction of a protocol integrating the use of the Dragger JM-105 transcutaneous bilirubinometer in the postnatal ward. Only babies born at ≥37 weeks of gestation, weighing ≥2500 g who presented with jaundice after the first 24 hours and within the first 7 days of life were included in the study. The number of total serum bilirubin samples (TSBRs) sent were compared for the 6-month periods before and after (a total of 12 months) implementation of the new protocol.

RESULTS

In the pre-implementation phase, a total of 882 (49%) out of 1815 babies had at least one serum bilirubin sample taken as opposed to a total of 236 (17%) out of 1394 babies in the post-implementation phase. The odds of performing TSBRs at least one time among babies in post-implementation phase were 79% lower than in pre-implementation phase (OR 0.21, 95% CI 0.18 to 0.25). We also estimated a significant cost saving of approximately US$1800 over a period of 6 months.

CONCLUSION

TcBR testing used in conjunction with our proposed nomogram significantly reduces the need for serum bilirubin sampling.

The current landscape of European registries for rare endocrine conditions

Objective To identify cross-border international registries for rare endocrine conditions that are led from Europe and to understand the extent of engagement with these registries within a network of reference centres (RCs) for rare endocrine conditions. Methods Database search of international registries and a survey of RCs in the European Reference Network for rare endocrine conditions (Endo-ERN) with an overall response rate of 82%. Results Of the 42 conditions with orphacodes currently covered within Endo-ERN, international registries exist for 32 (76%). Of 27 registries identified in the Orphanet and RD-Connect databases, Endo-ERN RCs were aware of 11 (41%). Of 21 registries identified by the RC, RD-Connect and Orphanet did not have a record of 10 (48%). Of the 29 glucose RCs, the awareness and participation rate in an international registry was highest for rare diabetes at 75 and 56% respectively. Of the 37 sex development RCs, the corresponding rates were highest for disorders of sex development at 70 and 52%. Of the 33 adrenal RCs, the rates were highest for adrenocortical tumours at 68 and 43%. Of the 43 pituitary RCs, the rates were highest for pituitary adenomas at 43 and 29%. Of the 31 genetic tumour RCs, the rates were highest for MEN1 at 26 and 9%. For the remaining conditions, awareness and participation in registries was less than 25%. Conclusion Although there is a need to develop new registries for rare endocrine conditions, there is a more immediate need to improve the awareness and participation in existing registries.

Maternal Predictors of Intrauterine Growth Retardation

OBJECTIVE

To identify maternal factors associated with intrauterine growth restriction (IUGR).

STUDY DESIGN

A case-control study.

PLACE AND DURATION OF STUDY

Neonatal Unit of The Aga Khan Hospital for Women (AKHW), Karimabad, from January 2014 to December 2015.

METHODOLOGY

Cases were IUGR live born babies (n=90), while control were appropriate-for-gestational age (AGA) babies (n=180). Information recorded in pre-designed proforma included gestational age and birth weight of baby, demographics of mothers, pregnancy related medical and obstetric complications. Data were analysed through SPSS-19. Multivariable logistic regression was used to determine the maternal factors associated with the intrauterine growth restriction.

RESULTS

Maternal factors associated with IUGR after adjusting for confounders in the multivariable model included younger age (OR=0.9, CI=0.8-0.9), poor gestational weight gain (OR=3.0, CI=1.6-6.1) and history of previous abortion (OR=3.06, CI=1.1-8.0). Significant interaction was found between pregnancy-induced hypertension (PIH) and parity of mother, primary-para mother with PIH having an increased risk for IUGR babies (OR=10.1, CI=1.0-23.2).

CONCLUSION

Young age, primigravida status, low gestational weight gain, previous history of abortion, PIH and GDM have strong association with IUGR; hence, special consideration is essential to overcome these issues in order to improve maternal and neonatal health.

Meconium stained liquor and its neonatal outcome

Objective:

To determine the maternal factors and neonatal outcome of pregnancy complicated by meconium stained amniotic fluid.

Methods:

This one year retrospective study was conducted at the Agha Khan Hospital for Women-Garden Campus, it is a secondary care private teaching hospital. Demographics information included gestational age, gender and birth weight of baby, medical and obstetric complications during pregnancy, mode of delivery, neonatal outcome (Meconium Aspiration Syndrome (MAS) and need for admission in nursery) were recorded on a pre-designed proforma.

Results:

In our study the frequency of meconium stained amniotic fluid (MSAF) was 7.85%, out of them 12 % babies developed MAS. There was significant association between grades of meconium and MAS, babies with thick meconium were prone to develop MAS (P = 0.02). Emergency cesarean section was significantly associated with MAS. Gestational diabetes (GDM) and pregnancy induced hypertension (PIH) were the significant factors associated with MAS.

Conclusion:

Thick Meconium stained amniotic fluid was associated with low APGAR score, high rate of emergency cesarean section and meconium aspiration syndrome. Anemia during pregnancy, PIH and GDM were important risk factor associated with MAS.

Childhood-Onset Systemic Lupus Erythematosus: A Cohort Study

OBJECTIVE

To determine the clinical and immunological characteristics and short-term outcome of children with systemic lupus erythematosus (SLE).

STUDY DESIGN

A descriptive cohort study.

PLACE AND DURATION OF STUDY

Paediatric Rheumatology Clinic, The Aga Khan University Hospital, Karachi, from January 2011 to December 2015.

METHODOLOGY

Clinical and immunological profile and short-term outcome of children less than 16 years of age admitted in the paediatric ward, with the diagnosis of SLE was studied. Demographic data, clinical presentation, laboratory findings, immunological profile and treatment regimens of these children were evaluated.

RESULTS

Thirty-two children, satisfying the criteria of American College of Rheumatology (ACR) for SLE, were enrolled during the study period of five consecutive years. A female predominance was observed with 28 (87.5%) patients being female (F:M 7:1). Mean age at symptom onset was 10.5 +2.7 years; and 8.8 +2.1 years in females and males, respectively. The mean age at diagnosis was 11.3 +2.8 years in females and 9.4 +1.9 years in males. Prolonged fever was the most common non-specific symptom found in 27 (84%), followed by pallor in 13 (41%) patients. Twenty-two (69%) children were found to be anemic and 18 patients (56%) having signs of arthritis at presentation. Renal involvement was observed in 15 (47%) patients. The most common laboratory finding was anemia, found in 22 (69%) of cases. The most common immunological markers were serum anti-neutrophil antibodies (ANA), positive in 28 (88%) patients, followed by anti double-stranded DNA antibodies, raised in 26 (81%) of cases. Out of 32, 12 patients were lost to follow-up. Of the remaining 20 children who were followed for four years, ten (50%) went into remission.

CONCLUSION

Childhood-onset SLE encompasses a wide variety of manifestations with a female preponderance. Fever, arthralgia and pallor are the most frequent clinical manifestations among the children. Hemolytic anemia (HA) is the most common laboratory abnormality, with ANA and anti ds-DNA antibodies positivity in the majority of padiatric patients.

Fludrocortisone-a treatment for tubulopathy post-paediatric renal transplantation: A national paediatric nephrology unit experience

Calcineurin inhibitors post-renal transplantation are recognized to cause tubulopathies in the form of hyponatremia, hyperkalemia, and acidosis. Sodium supplementation may be required, increasing medication burden and potentially resulting in poor compliance. Fludrocortisone has been beneficial in addressing tubulopathies in adult studies, with limited paediatric data available. A retrospective review of data from an electronic renal database from December 2014 to January 2016 was carried out. Forty-seven post-transplant patients were reviewed with 23 (49%) patients on sodium chloride or bicarbonate. Nine patients, aged 8.3 years (range 4.9-16.4), commenced fludrocortisone 22 months (range 1-80) after transplant and were followed up for 9 months (range 2-20). All patients stopped sodium bicarbonate; all had a reduction or no increase in total daily doses of sodium chloride. Potassium levels were significantly lower on fludrocortisone, 5.2 vs 4.5 mmol/L, P = .04. No difference was noted in renal function (eGFR 77.8 vs 81.7 mL/min/1.73 m² , P = .45) and no significant increase in systolic blood pressure (z-scores 0.99 vs 0.85, P = .92). No side effects secondary to treatment with fludrocortisone were reported. A significant proportion of renal transplant patients were on sodium supplementation and fludrocortisone reduced sodium supplementation without significant effects on renal function or blood pressure. Fludrocortisone appears to be safe and effective for tubulopathies in children post-transplantation.

Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change

There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth-restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks' postmenstrual age (6 months' corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.

A protocol for quality improvement programme to reduce central line-associated bloodstream infections in NICU of low and middle income country

INTRODUCTION

Central line-associated bloodstream infections (CLABSI) are the most important cause of morbidity and mortality in critically ill patients. Evidence-based interventions when used in form of a bundle have proven to decrease CLABSI. Our unit has a high CLABSI rate (9/1000 central line days). Therefore, we intend to introduce evidence-based CLABSI prevention package in our practice to improve CLABSI rates in our NICU within limited resources.

METHODS AND ANALYSIS

The study will be conducted using preanalysis and postanalysis design from January 2016 to December 2017. It is going to be conducted in three phases with phase I being the preimplimentation phase where retrospective data will be collected. Phase II, implementation phase, where the CLABSI prevention package will be introduced and phase III will be follow-up to see the impact. Primary outcome will be reduction in CLABSI rates.

ANALYSIS PLAN AND REPORTING

For all three phases, descriptive analysis will be performed. Nominal data will be presented as mean±SD, whereas categorical data will be presented as frequencies and percentages. To compare the effect of intervention we will use independent sample t-test for continuous outcomes, whereas Χ2 test will be used for categorical outcomes. Relative risk ratios, 95% CI, and p values will be determined. Incidence density will be calculated and Poisson regression will be used to determine factors associated with incidence of CLABSI. Microbiological profiles and antimicrobial resistance pattern will be reported as pan sensitive, multidrug-resistant organism and carbapenem-resistant organism. SQUIRE V.2.0 guidelines will be used for manuscript writing and reporting.

Congenital neonatal scalp arteriovenous malformation: a very rare entity

Congenital arteriovenous malformations (AVMs) of scalp are rare congenital vascular malformations. They are usually not symptomatic at birth and are often misdiagnosed as haemangiomas. To date, only two cases of symptomatic neonatal scalp AVM have been reported in literature. Pathophysiology of congenital AVM is not completely understood but genetic and acquired causes are implicated. Diagnosis and management are often difficult and require multidisciplinary approach. We report a rare case of symptomatic congenital scalp AVM in a 10-day-old neonate who was successfully managed at our unit.

Effectiveness of transcutaneous bilirubin measurement in managing neonatal jaundice in postnatal ward of a tertiary care hospital in Pakistan

INTRODUCTION

Neonatal jaundice is a common cause of concern in immediate newborn period for parents as well as for the caregivers. Babies with visible jaundice are identified by the healthcare provider, and blood samples are sent for confirmation. Clinical expertise varies from person to person and may lead to sending excessive blood sampling. Obtaining blood bilirubin samples is a painful procedure; it predisposes the baby to infections and requires skilled health personnel. Moreover, laboratory tests are costly and time consuming, leading to unnecessary delays in commencing phototherapy and discharge from hospital. Transcutaneous bilirubinometer has been in use for a long time as screening tool in postnatal wards. With passage of time, its accuracy and validity have improved tremendously.

METHODOLOGY

We aim to implement a quality improvement initiative to reduce the number of blood bilirubin samples using transcutaneous bilirubin (TcBR) nomogram in full-term, low-risk babies who are born at our hospital and are admitted in postnatal ward after birth. Using preanalysis and postanalysis study design, this study will be performed in two phases of 6 months each. Data regarding total number of admissions in postnatal wards, demographics, serum bilirubin(TSBR) samplings and need for phototherapy will be recorded in both phases. TcBR will be done and recorded in postimplementation phase.

ANALYSIS AND RESULTS

Comparisons between the two groups will be made. Primary outcome will be reduction in blood bilirubin samples for TSBR after the implementation of TcBr protocol. The proportion of infants having TSBR performed in both periods will be compared. Crude sampling cost of TSBR will be obtained from laboratory, and cost comparison between two phases will be done to look for difference.

Right-Sided Congenital Diaphragmatic Hernia and Myelomeningocele: A Rare Association

Congenital diaphragmatic hernia (CDH) is a rare birth defect with a prevalence of < 0.5 per 1,000 live births. Majority of these defects are left-sided as most studies suggest that frequency of right-sided CDH was 10% of the total. The association of CDH with myelomeningocele (MMC) is extremely rare; as in Sweed's study of 116 consecutive cases of CDH, the incidence of associated MMC with CDH was stated as 4.3%. There has been one previous case report of leftsided CDH, MMC and hydrocephalus prenatally diagnosed; but to the best of authors' knowledge, this is the first reported case of the above constellation with a right-sided CDH diagnosed prenatally.

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.

Vascular Ehlers-Danlos syndrome: a rare disorder presenting with focal convulsions

Vascular Ehlers-Danlos Syndrome (VEDS), previously called Ehlers-Danlos syndrome type-IV, is a heterogeneous group of heritable connective tissue disorders characterized by thin, translucent skin, easy bruising, arterial, intestinal, and/or uterine fragility. There is large vessel involvement that leads to arterial rupture often preceded by aneurysm, arteriovenous fistulae, or dissection. Noninvasive imaging studies such as CT angiography and MR angiography are preferred as diagnostic studies for this condition. We are reporting a 4 years old girl who was presented with right sided unilateral convulsions and hypertension. CT angiogram showed stenosis with post-stenotic dilatation of coeliac and superior mesenteric arteries. There were extensive calcified plaques with atherosclerotic changes in the segment of right common iliac artery with aneurysmal dilatation of celiac, superior mesenteric and common iliac artery. Radiological findings were consistent with vascular Ehlers-Danlos syndrome. She was successfully managed with anti-hypertensive and anticonvulsants.

Risk factors for intraventricular haemorrhage in preterm infants from a tertiary care hospital of Karachi, Pakistan

OBJECTIVE

To determine the incidence of Intraventricular Haemorrhage in pre-term infants, along with adverse neonatal outcomes associated with the disease.

METHODS

The retrospective case control study was conducted at Aga Khan University Hospital, Karachi, and comprised patients' records from January 2004 to December 2009 of preterm babies from 26-35 weeks of gestation who had Intraventricular Haemorrhage of any grade. The diagnosis was confirmed by ultrasound scan. Controls were preterm births matched with the cases according to gestational age (±1 week) and birth weight (±150 grams). SPSS 19 was used for statistical analysis.

RESULT

Of the total 201 preterm babies in the study, there were 67(33.33%) cases and 134(66.66%) controls; the respective ratio being 1:2.The incidence of Intraventricular Haemorrhage in the study population was 22.1 per 1000 live births.The odds of developing Intraventricular Haemorrhage was substantially higher in babies with respiratory distress syndrome (odds ratio: 3.77; 95% Confidence Interval: 1.52-9.37; p < 0.004) and who were given mechanical ventilation (odds ratio: 23.6; 95% Confidence Interval: 5.09-109.5; p < 0.001). There was a four-fold increase in risk of Intraventricular Haemorrhage in babies who received surfactant administration (odds ratio: 4.26; 95% Confidence Interval: 1.77-10.22; p < 0.001). Out of 67 cases, 50 (74.6%) re-demonstrated the same grade, 13 (19.4%) were resolved, and 4 (6%) progressed. Overall, there were 38 death; the mortality rate being 56.71.

CONCLUSION

The risk of Intraventricular Haemorrhage was substantially higher in preterm neonates with respiratory distress syndrome, etc., and the mortality rate was higher in babies with severe disease.

Clinical and biochemical characteristics of children with juvenile idiopathic arthritis

OBJECTIVE

To determine the clinical and biochemical characteristics of children with Juvenile Idiopathic Arthritis (JIA) at a tertiary care centre in Karachi, Pakistan.

STUDY DESIGN

A descriptive study.

PLACE AND DURATION OF STUDY

Paediatric Rheumatology Clinic of The Aga Khan University Hospital (AKUH), Karachi, from January 2008 to December 2011.

METHODOLOGY

Clinical and laboratory profile and outcome of children less than 15 years of age attending the Paediatric Rheumatology Clinic of the Aga Khan University, Karachi with the diagnosis of Juvenile Idiopathic Arthritis according to International League against Rheumatism were studied. These children were classified into different types of JIA; their clinical and laboratory characteristics, response to therapy and outcome was evaluated.

RESULTS

Sixty eight patients satisfying the criteria of International League against Rheumatism (ILAR) for Juvenile Idiopathic Arthritis were enrolled during the study period of four consecutive years, their age ranged from 9 months to 15 years. Mean age at onset was 6.45 ± 4.03 years while mean age at diagnosis was 7.60 ± 3.93 years. Polyarticular was the most predominant subtype with 37 (54%) patients, out of these, 9 (24%) were rheumatoid factor positive. An almost equal gender predisposition was observed. Fever and arthritis were the most common presenting symptoms, with only 2 patients presenting with uveitis.

CONCLUSION

The clinico-biochemical characteristics of JIA at the study centre showed a pattern distinct with early onset of disease, high frequency of polyarticular type and a higher rheumatoid factor (QRA) and ANA positivity in girls.

Short-term neonatal outcome in late preterm vs. term infants

OBJECTIVE

To determine the short-term neonatal outcomes in late preterm infants (LPI's) as compared to term infants and their association with maternal risk factors.

STUDY DESIGN

A case control, descriptive study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital, Karachi, Pakistan, from January to December 2009.

METHODOLOGY

The study included 326 late preterm babies (defined as those born between 340⁄7 to 376⁄7 weeks of gestation) and equal number of term control babies at the Aga Khan University Hospital, Karachi, Pakistan. Data, including obstetric history, maternal complications, neonatal morbidities, etc., was retrieved from patients' medical records. The data was compared with the control group for complications, fetal morbidity and maternal morbidity.

RESULTS

Late preterm infants constituted 10.6% of all deliveries and 77% of all live preterm births during the study period. Respiratory distress syndrome (RDS) (16.5% vs. 0.3%, p < 0.001), growth retardation (24.8% vs. 4%, p < 0.001), hyperbilirubinemia requiring phototherapy (37.9% vs. 11%, p < 0.001), and sepsis (4.9% vs. 0.3%, p < 0.001) were found to be the major morbidities in the study group. The need for resuscitation was 12.7 times higher in the study group as compared to the term babies (21.4% vs. 1.2%, p < 0.001). NICU admissions in the study group were also higher (18.8% vs. 2.4%, p < 0.001). Hypertension (12.5% vs. 1.5%, p < 0.001), diabetes (12.5% vs. 9.2%, p < 0.001), antenatal history of UTI (1.5% vs. 0.3%, p < 0.001), and prolong rupture of membrane (8.9% vs. 4%, p < 0.001) were significant maternal morbidities in the late preterm group.

CONCLUSION

The late preterm group had greater morbidity, compared to term neonates. Prior awareness of the morbidities associated with late preterm babies is helpful for the health care providers to anticipate and manage potential complications in late preterm infants.

Morbidity pattern of sick hospitalized preterm infants in Karachi, Pakistan

Despite recent advances, prematurity is associated with high morbidity and mortality in developing countries. We conducted a descriptive case series to identify frequency of various morbidities in premature neonates at Aga Khan University Hospital (AKUH), Karachi, from November 2008 to April 2009. All inborn premature < or = 37 weeks gestation were included in study. The frequency of preterm birth during study period was 13.3% (251/1885) of which 58% (n = 145) required admission in Neonatal Intensive Care Unit (NICU). Mean gestational age was 33 +/- 2.4 weeks and mean birth weight, was 1.88 +/- 0.5 kg. 25% of patients were small for gestational age (SGA) while 75% appropriate for gestational age (AGA). Metabolic derangement was the most common morbidity, observed in 93% of patients followed by sepsis, seen in 43.6% neonates. Respiratory distress syndrome was observed in 35.5% of neonates while intraventricular haemorrhage was seen only in 3.5% patients. Mean length of stay for preterm infants in NICU was 11.5 +/- 9.6 days, 14% (n = 20) preterm neonates expired during NICU stay.

Foetus-in-Foetu

Foetus-in-foetu is a rare malformation in which a monozygotic diamniotic parasitic twin is incorporated into the body of its fellow twin and grows inside it. Less than 100 cases have been reported in literature. One day old newborn male was admitted with antenatal diagnosis of abdominal mass. It was cystic/solid in nature with pressure effects on left ureter and urinary bladder, most likely to be a germ cell tumour. Birth history was uneventful. Exploratory laparotomy was performed and the mass was excised. Physical examination confirmed the diagnosis of foetus-in-foetu. Although it is a rare condition, imaging may play an important role in the correct prospective diagnosis of foetus-in-foetu. Surgical excision is the recommended treatment.

Observation of long spin-relaxation times in bilayer graphene at room temperature

We report on the first systematic study of spin transport in bilayer graphene (BLG) as a function of mobility, minimum conductivity, charge density, and temperature. The spin-relaxation time τ(s) scales inversely with the mobility μ of BLG samples both at room temperature (RT) and at low temperature (LT). This indicates the importance of D'yakonov-Perel' spin scattering in BLG. Spin-relaxation times of up to 2 ns at RT are observed in samples with the lowest mobility. These times are an order of magnitude longer than any values previously reported for single-layer graphene (SLG). We discuss the role of intrinsic and extrinsic factors that could lead to the dominance of D'yakonov-Perel' spin scattering in BLG. In comparison to SLG, significant changes in the carrier density dependence of τ(s) are observed as a function of temperature.

Klebsiella osteomyelitis of the right humerus involving the right shoulder joint in an infant

Osteomyelitis in newborn infants is a rare infection. Lower extremity joints are commonly affected. Most of the cases have a haematogenous spread. Aerobes are the common group of organism involved, of which Staphylococcus aureus is the commonest. Klebsiella osteomyelitis has been reported as a cause of Osteomyelitis. However, to the best of our knowledge, this is the first case report of Klebsiella pneumoniae associated osteomyelitis in an infant from Pakistan.

Pan-resistant Acinetobacter infection in neonates in Karachi, Pakistan

BACKGROUND

Pan-resistant Acinetobacter infection has emerged as an important nosocomial pathogen in our inpatient neonates over the past few years.

METHODOLOGY

We performed a retrospective chart review during a five-year period (July 2003 - June 2008) of all neonates hospitalized in our neonatal intensive care unit (NICU) who developed Acinetobacter infection to identify mortality-associated risk factors in Acinetobacter neonatal infection.

RESULTS

During the five-year study period, 122 cultures from 78 neonates grew Acinetobacter. Source sites of positive culture were in the following descending order: blood (n = 57), trachea (n = 55), tissue/wound/body fluids (n = 4), eye (n = 4), urine (n = 1), and cerebrospinal fluid (n = 1). Twenty-four (31%) patients had Acinetobacter isolated from more than one site. At the time of admission the mean age was 2.08 +/- 4 days and mean weight was 1.77 +/- 0.88 kg; 75% were premature. Pan-resistance (87/122; sensitive only to Polymyxin) was present in 71% of Acinetobacter isolates. Crude mortality rate of this cohort was 47%, while 70% of patients died within four days after positive Acinetobacter culture. We identified weight of less than 1 kg on admission (p 0.06, adjusted Odds Ratio (AOR) 1.53), gestational age 28 weeks or less (p 0.011, AOR 2.88), poor perfusion (p 0.007, AOR 2.4), thrombocytopenia (p 0.01; AOR 1.6) and metabolic acidosis (p 0.01; AOR 1.67) as predictors associated with poor outcome.

CONCLUSION

Pan-resistant Acinetobacter infection is exceedingly fatal in newborns, particularly in premature and very low-birth weight neonates. Rational antibiotic use and vigilant infection control in NICUs are key to controlling multi-drug resistant Acinetobacter infection and improving clinical outcome.

Pan-resistant Acinetobacter Infection in Neonates in Karachi, Pakistan

Background: Pan-resistant Acinetobacter infection has emerged as an important nosocomial pathogen in our inpatient neonates over the past few years. Methodology: We performed a retrospective chart review during a five-year period (July 2003 - June 2008) of all neonates hospitalized in our neonatal intensive care unit (NICU) who developed Acinetobacter infection to identify mortality-associated risk factors in Acinetobacter neonatal infection. Results: During the five-year study period, 122 cultures from 78 neonates grew Acinetobacter. Source sites of positive culture were in the following descending order: blood (n = 57), trachea (n = 55), tissue/wound/body fluids (n = 4), eye (n = 4), urine (n = 1), and cerebrospinal fluid (n = 1). Twenty-four (31%) patients had Acinetobacter isolated from more than one site. At the time of admission the mean age was 2.08 ± 4 days and mean weight was 1.77 ± 0.88 kg; 75% were premature. Pan-resistance (87/122; sensitive only to Polymyxin) was present in 71% of Acinetobacter isolates. Crude mortality rate of this cohort was 47%, while 70% of patients died within four days after positive Acinetobacter culture. We identified weight of less than 1 kg on admission (p 0.06, adjusted Odds Ratio (AOR) 1.53), gestational age 28 weeks or less (p 0.011, AOR 2.88), poor perfusion (p 0.007, AOR 2.4), thrombocytopenia (p 0.01; AOR 1.6) and metabolic acidosis (p 0.01; AOR 1.67) as predictors associated with poor outcome.    Conclusion: Pan-resistant Acinetobacter infection is exceedingly fatal in newborns, particularly in premature and very low-birth weight neonates. Rational antibiotic use and vigilant infection control in NICUs are key to controlling multi-drug resistant Acinetobacter infection and improving clinical outcome.

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.

Multiple major artery compression by an idiopathic aortic aneurysm: an unusual cause of hypertensive encephalopathy

Multiple major artery compression by an aortic aneurysm is extremely rare in the paediatric population. Most arterial aneurysms in children are secondary to infections mainly mycotic, connective tissue disorder, vasculitis, collagen vascular diseases, and other causes. True idiopathic aneurysms are the least common and a few reports in children have been published. We describe an 8 year old boy who presented with hypertensive encephalopathy and later was found to have an idiopathic, symptomatic suprarenal aortic aneurysm compressing multiple major arteries of the abdomen. The child was subsequently managed on multiple antihypertensive medication and later required engraftment of the renal and inferior mesenteric artery. The diagnostic workup, surgical treatment, and a review of the literature is described.

Characterization of silicone breast implant biopsies by Fourier transform infrared mapping

Fourier transform infrared (FT-IR) spectral mapping was used to study polymers in human tissue associated with silicone breast implants. Biomaterials such as polyesters, polyurethanes and silicone were identified by FT-IR spectroscopy, and their relative locations and distributions within tissue specimens were characterized by three-dimensional (3D) spectral maps.

Determination of picomole amounts of glycerate 3-phosphate, glycerate 2-phosphate, and phosphoenol pyruvate by an enzymatic assay coupled to firefly luciferase/luciferin luminescence

A procedure for the determination of picomole amounts of glycerate 3-phosphate, glycerate 2-phosphate, and phosphoenol pyruvate is described. These metabolites were utilized by the glycolytic enzymes phosphoglycerate mutase, enolase, and pyruvate kinase to generate ATP which was determined by firefly luciferase/luciferin luminescence. The phosphoglycerate mutase used was of the glycerate 2,3-bisphosphate-independent type and was prepared from wheat germ. Stoichiometric conversion of glycerate 3-P, ranging in amount from 9 to 275 pmol, occurred after 25 min preincubation and required a narrow range of added mutase. The application of the procedure for determining these metabolites in suspensions of plant protoplasts is described.

Enzyme polymorphism in Drosophila melanogaster populations in Iraq

Electrophoretic studies of the degree and pattern of polymorphism at two third-chromosome loci, esterase-6 (Est-6) and phosphoglucomutase (PGM), were carried out in three Drosophila melanogaster populations collected from different localities in Iraq: Mosul, Tuwaitha, and Basrah. The results show that only the Tuwaitha population was polymorphic for both loci; the other two populations were polymorphic for Est-6 and monomorphic for PGM. The allele frequency changes at both loci were followed for 20 generations in an experimental cage derived from the Tuwaitha population; it was found that there is a deviation from Hardy-Weinberg equilibrium at both loci toward the homozygote.

Immunization of sheep against Theileria hirci infection with schizonts propagated in tissue culture

Two experiments were carried out. In the first, three groups of lambs were inoculated subcutaneously with 3 X 10(6) schizonts of different passages (3, 30 and 63) of Theileria hirci propagated in tissue culture. Severe reactions were observed in lambs inoculated with organisms derived from the 3rd passage. In the second experiment, four groups were inoculated with 5 X 10(5), 3 X 10(6), 1 X 10(7) and 5 X 10(8) schizonts of the 63rd passage. No clinical reactions or parasites were detected in lambs inoculated with 5 X 10(5) schizonts. Mild reactions were observed in lambs inoculated with 3 X 10(6), 1 X 10(7), and 5 X 10(7) schizonts. Lambs inoculated with 3 X 10(6) schizonts were resistant to challenge with a virulent strain. The indirect fluorescent antibody (IFA) test was used to determine the antibody titre.