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  Most popular articles (Since March 10, 2017)

 
 
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ORIGINAL ARTICLES
Implementation of ventilator associated pneumonia prevention bundle in the neonatal intinsive care unit at Alexandria University Children’s Hospital, Egypt
Reem M.A Tayel, Abd El Haleem A Badr El Din, Soad F Hafez, Bahaa S Hammad
May-August 2017, 30(2):74-83
DOI:10.4103/AJOP.AJOP_19_17  
Introduction Ventilator-associated pneumonia (VAP) is a nosocomial lung infection that develops at or later than 48 h after mechanical ventilation (MV). It is the second most frequent hospital-acquired infection in neonatal intensive care units (NICUs). It results in high morbidity, mortality, prolonged NICU length of stay, and increased cost of hospitalization. Egypt and other developing countries report higher VAP rates compared with developed countries. Furthermore, studies monitoring VAP rates and success of intervention strategies in Egyptian NICUs are few. Aim The aim of the present study was to estimate the incidence of VAP during the implementation of the prevention bundle and also to identify the causative agents and significant risk factors in the NICU at Alexandria University Children’s Hospital. Patients and methods A nonrandomized clinical trial with historical control was conducted. All neonates admitted to the NICU in the period from July 2015 till March 2016, who spent more than 48 h on MV, were subjected to a VAP prevention bundle. Eligible neonates who spent more than 48 h on MV were monitored closely for VAP development. A thorough assessment of history, clinical examination, routine investigations, and chest radiography were carried out on all enrolled infants. Neonates who developed clinically suspected VAP were further subjected to nonbronchoscopic bronchoalveolar lavage for bacteriological confirmation of the clinical diagnosis. A review of records was performed to determine the incidence of VAP in the 9 months before intervention. Oral swabs were taken to study the pattern of oral colonization in ventilated neonates to trace its role in VAP development. Also, cultures of residual gastric volume and water traps inserted into the ventilator circuits were studied. Results A total of 108 episodes of VAP were diagnosed, with a cumulative incidence of clinically diagnosed VAP equal to 37.6% (34.2 VAP cases/1000 ventilation days). The incidence of bacteriological-confirmed VAP in this study was 19.97/1000 ventilation days. The most important risk factors for the occurrence of VAP were prematurity, low birth weight, prolonged duration of ventilation, re-intubations, and enteral feeding. Gram-negative bacteria were the predominating cause of VAP in the NICU and Klebsiella was the most common pathogen isolated from nonbronchoscopic bronchoalveolar lavage cultures. Conclusion VAP is a severe complication of MV as it significantly increases neonatal mortality. The VAP preventive bundle implemented in the present work was associated with a reduction in the VAP rate in the NICU.
  1,087 99 -
Hypochromic microcytic anemia: a clincopathological cross-sectional study
Mostafa A.S Salama, Maha Y Kamal, Doren N.A Younan, Gehad A.A Henish
January-April 2017, 30(1):37-43
DOI:10.4103/AJOP.AJOP_8_17  
Background Iron-deficiency anemia, the most common cause of microcytic anemia, is a worldwide nutritional problem; its prevalence in the developing countries is three times higher than in the developed countries. It is a common disease in Egypt with a very high prevalence rate. It affects all age groups and all socioeconomic levels of the society. Identification of infants who are at risk for iron deficiency anemia (IDA) is vital as it impairs psychomotor development and growth and reduces physical activity and resistance to infection. Aim The aim of this work was to assess the prevalence of IDA among infants aged 6 months and 2 years presenting with hypochromic microcytic anemia and to determine the risk factors of iron deficiency among this age group. Participant and methods A total of 40 infants (6 months and 2 years) presenting with hypochromic microcytic anemia attending Alexandria University Children’s Hospital were included in this study. All were subjected to complete blood count, iron profile [serum ferritin (SF), serum iron, and total iron-binding capacity], and finding occult blood in stool. Those having normal iron profile were further subjected to capillary hemoglobin (Hb) electrophoresis and PCR for α-chain gene mutations to exclude β-thalassemias and α-thalassemias. Results Overall, 77.5% (31/40) of the studied infants had IDA, which represents the main cause of microcytic anemia in this study, whereas 17.5% (7/40) had β-thalassemia trait, diagnosed by increased HbA2 more than 3.5% by capillary Hb electrophoresis, and 5% (2/40) had α-thalassemia trait of the homozygous α3.7 (−α3.7/−α3.7) deletional type, detected by PCR for α-gene mutations. Moreover, this study showed that infants with IDA had significantly higher frequencies of preterm deliveries (48.38%) compared with β-thalassemia trait (14.28%), and α-thalassemia trait (0%), P=0.023, KWχ2=4.849. A significant positive correlation was found between Hb, serum iron, and SF levels of infants with IDA and both maternal Hb during pregnancy (r=0.937, P<0.001; rs=0.796, P<0.001; and rs=0.780, P<0.001, respectively) and maternal age (r=0.791, P<0.001; rs=0.749, P<0.001; and rs=0.671, P<0.001, respectively). The mean±SD weight of infants with IDA (9.91±1.61 kg) was significantly lower than that of infants having other microcytic anemias, P=0.039, KWχ2=5.659. Among infants with IDA, only five started weaning at an appropriate age, i.e., between 4 and 6 months, and their SF levels ranged between 8 and 9.4 μg/l, with a mean±SD of 8.58±1.10, which was statistically significantly higher than the SF levels among those who started weaning later (>6 months) (n=26), whose SF levels ranged between 2.0 and 5.9 μg/l, with a mean±SD of 4.04±1.10, P=0.001. Conclusion High prevalence of IDA was detected among infants presenting with microcytic hypochromic anemia (77.5%). The main risk factors for developing IDA include inadequate iron intake, preterm delivery, delayed onset of weaning, occult blood loss in stools owing to either early introduction of cow’s milk or parasitic infestations, and finally, infants born to young or anemic mothers.
  824 87 -
Clinical and laboratory study of infants and children with Bartter syndrome attending Alexandria University Children’s Hospital (10 years experience)
Mohamed Thabet, Ola A Sharaki, Hanan M Fathy, Ahmed Z.Z Ayoub
January-April 2017, 30(1):1-10
DOI:10.4103/AJOP.AJOP_2_17  
Background Bartter syndrome (BS) is a group of inherited, salt-losing tubulopathies presenting as metabolic alkalosis with normotensive hyperreninemia and hyperaldosteronism. It is a consequence of abnormal function of the kidneys, which become unable to properly regulate the volume and composition of body fluids because of defective reabsorption of NaCl in loop of Henle. A first consequence of the tubular defect in BS is polyuria, which is responsible for particular complications of pregnancy − that is, polyhydramnios and premature delivery. Low potassium levels in the blood may result from overactivity of the renin–angiotensin II–aldosterone hormone system that is essential in controlling blood pressure. To date, at least five genes have been linked to BS, and they characterize five types of BS. Aim The aim of this work is to study the clinical and laboratory data of infants and children with BS attending Alexandria University Children’s Hospital during a 10-year period (January 2004–December 2013). Participants and methods A retrospective analysis of children diagnosed with BS attending Alexandria University Children’s Hospital during a 10-year period (January 2004–December 2013) was carried out. On the basis of the clinical, biochemical features, and ultrasonographic findings, 20 children were diagnosed with BS. Their demographic, clinical, biochemical, and hormonal profiles were analyzed. Follow-up data and outcomes were recorded. Results The majority of cases had perinatal history of polyhydraminos. All cases had high urinary chloride in spot urine analysis. The mainstay of treatment in BS is potassium supplementation and indomethacin. Correction of hypokalemia and hyperprostaglandinemia are mandatory for improving the symptoms (vomiting, polyuria) and chronic sequalae such as FTT and growth retardation. Conclusions According to this study, BS should be suspected in any child with a history of failure to thrive and metabolic alkalosis. Early diagnosis and treatment with NSAIDs are life-saving.
  709 140 -
Challenges and adjustments of mothers having children with autism
Tarek E.I Omar, Wafaa M Ahmed, Nehad S Basiouny
September-December 2017, 30(3):120-129
DOI:10.4103/AJOP.AJOP_4_18  
Background Children with autism and their families especially their mothers face numerous and pervasive challenges. In addition to the expected concerns with behavior, communication, and morbidities, mothers expressed deep apprehension about their child’s isolation and meaningful integration into daily life. Difficulties to access a quality care, financial burden, issues of adulthood, and their child’s challenging behaviors may produce significant stressors to mothers. Healthcare providers should take these challenges into consideration when providing care to those children and their mothers. Aim The aim of this study was to assess the challenges and adjustments of mothers having children with autism. Patients and methods A convenient sample of 76 mothers who have children with autism represented the participants. They were recruited from the Neurological Outpatient Clinic of Alexandria University Specialized Children’s Hospital at Smouha, Egypt. Three tools were used to collect the data as: (i) Mothers’ Sociodemographic Data Interview Schedule, (b) Stressors of Mothers who have Children with Autism Interview Schedule 3. Parent and Family Adjustment Scale. Results Overall, 71.4% of the mothers who were in the age 40 to <50 years had moderate stressors percent score. More than half of mothers sometimes had feelings of anger and nervousness. Furthermore, they had anhedonia and were unable to do anything alone. There was a statistically significant difference between mothers’ total percent score of stressors and their adjustment regarding psychological, social, and management-related stressors. Conclusion Mothers who have children with autism were confronted with multiple stressors. The most perceived stressors were physical, psychological, financial, community-related, and management-related stressors followed by social and marital stressors. Adjustment pattern were affected by various factors, such as mother’s age, social support, and family income related to employment of mothers. Recommendations Regular periodic meetings should be conducted between mothers and hospital personnel to promote proper communication.
  712 112 1
Effect of erythropoietin as adjunctive therapy with whole-body cooling for treatment of hypoxic-ischemic encephalopathy in newborns
Mohamed M Badr-El Din, Ahmed M.S.H Abougabal, Khalid M Saad, Hanan R Abdel-Salam
May-August 2017, 30(2):45-52
DOI:10.4103/AJOP.AJOP_14_17  
Background Hypothermia induced by whole-body cooling (WBC) and/or selective head cooling reduces brain injury after hypoxia-ischemia in newborns. Despite differences in approach (head cooling vs. total body cooling), there is a general agreement that hypothermia improves outcomes of moderately asphyxiated infants, decreasing the combined outcome of death and neurologic dysfunction from 60 to 45%. Subsequently, the search for adjuvant therapies that may provide long-lasting neuroprotection was mandatory. Aim of the present work The present study aimed to evaluate the short-term effects of erythropoietin (Epo) as a neuroprotective agent in adjunction with WBC to treat newborn infants with hypoxic-ischemic encephalopathy (HIE). Participants and methods This is a true interventional randomized controlled hospital-based study. A total of 33 full-term and late preterm newborn infants, delivered at El-Shatby Alexandria University Maternity Hospital, Egypt, were enrolled in the study. They fulfilled the criteria of HIE and received WBC during the first 6 h of life, in addition to the standard intensive care measures. Of the 33 studied babies, 11 received 500 IU/kg Epo every other day for 2 weeks as adjunctive therapy to WBC. Results The Epo plus WBC group (group I) had a significantly shorter period of hospital stay in comparison with the other group managed by WBC solely (group II), [mean hospital stay in days±SD: 6.20±2.39 and 8.40±3.94, respectively (P=0.039)]. The incidence of seizures was insignificantly lower among babies in group I. Extensive white and gray matter brain lesions were observed more among group II neonates, although the difference was statistically insignificant. Clinical and neurological improvements, as guided by Thomson score, were better achieved among group I babies, despite the difference being statistically insignificant. Conclusion Epo as an adjunctive therapy with WBC for treating asphyxiated neonates is a safe mode of therapy, which significantly shortens the period of hospital stay as well as it (marginally) improves their short-term outcome, both radiologically and clinically. WBC plus Epo lowers the rate of occurrence of clinically detectable seizures in the 1st week of life among asphyxiated neonates.
  692 108 -
A comparative study of the efficacy of using piracetam with iron therapy versus iron therapy alone in children with breath-holding spells
Bayoumi A Ghareib, Mona Khalil, Dina M Gaber
January-April 2017, 30(1):26-31
DOI:10.4103/AJOP.AJOP_6_17  
Background Breath-holding spells (BHS) are apparently frightening events occurring in otherwise healthy children. Generally, no medical treatment is recommended and parental reassurance is believed to be enough; however, in some cases BHS can be very stressful for the parents and a pharmacological agent may be desired in some of these children. Objective The aim of this work was to determine the efficacy of using piracetam with iron therapy versus iron therapy alone in children with BHS associated with iron-deficiency anemia. Study design The study design was an interventional randomized controlled one. Patients and methods This study was conducted at the Neuro-Pediatric Outpatient Clinic at Alexandria University Children’s Hospital, Egypt. A total number of 70 children between 6 months and 5 years of age with a diagnosis of BHS and iron-deficiency anemia reporting to the clinic were randomly divided into two groups: group I included 35 children who were given only iron therapy at a dose of 6 mg/kg/day, and group II included 35 children who were given iron therapy at the same dose and piracetam at a dose of 40 mg/kg/day. Follow-up of the cases monthly for 3 months was scheduled to evaluate the frequency of the attacks and the improvement in iron deficiency by evaluating iron profile after 3 months (iron, ferritin, and total iron binding capacity). Results Seventy patients were enrolled in this study (42 boys and 28 girls) and completed the study. The ratio of boys to girls was 3 : 2. The patients’ ages ranged between 6 months and 5 years at the time of presentation with 50% above 2 years of age. The frequency of spells varied widely, ranging from 1 to 3 per day to 3 per month, and the mean frequency was six episodes of BHS in 1 month (about 2/week) for both groups. On comparing the improvement in the frequency of attacks between the two studied groups after treatment, there was a significant difference (P=0.001) between the two groups; the median number of attacks was two attacks per month for group I and one attack per month for group II. Conclusion Treatment with piracetam in addition to iron therapy is better than iron therapy alone in reducing the frequency of breath-holding attacks in children with BHS associated with iron-deficiency anemia.
  620 133 -
Prevalence and etiology of communication disorders in children attending Alexandria University Children’s Hospital, Egypt
Bayoumi A Gharib, Manal M El Banna, Mona Khalil, Mai M Abou Heikal
January-April 2017, 30(1):17-25
DOI:10.4103/AJOP.AJOP_5_17  
Background Communication development in children usually follows a fairly predictable pattern, paralleling general cognitive development. Any problem in communication is likely to have a significant effect on a child’s social and academic skills and behavior. Objective The aim of this study was to estimate the prevalence and determine the possible etiologies of communication disorders in children attending the Outpatient Clinic of Alexandria University Children’s Hospital. Patients and methods Children attending the Outpatient Clinic of Alexandria University Children’s Hospital during a period of 6 months within the age range of 3–6 years were included in the study. A noninterventional descriptive cross-sectional hospital-based study was used. A structured questionnaire was used to identify communication complaints and their types from the parents’ perspectives besides their sociodemographic data. Children with positive complaints were evaluated using National Health Services-Lothian Guidelines for Referral to Speech and Language Therapy. The studied children underwent neurodevelopmental assessment and physical examination to identify possible etiologies of communication disorders and their distribution. Results In the studied sample of 280 children, the prevalence of significant communication complaints was 23.2% and the prevalence of confirmed communication disorders was 10%. The total prevalence of confirmed delayed language development (DLD) in the studied sample was 6.4%; 1.8% of the had specific language impairment, 1.4% had environmental DLD, 1.4% had DLD due to mental retardation, 1.1% had DLD associated with attention deficit hyperactivity disorder, and 0.7% had DLD due to autism spectrum disorders. The total prevalence of confirmed speech disorders in the studied sample was 3.2%; motor and speech-sound defects constituted 2.1% of the studied sample, 0.7% had dysfluency, and 0.4% had postadenoidectomy hypernasality. The total prevalence of confirmed voice disorders in the studied sample was 0.4%, with vocal polyp. Moreover, the study showed that sex, history of perinatal/postnatal events, and presence of medical health problems had significant effects on children’s communication development. Conclusion Communication disorders are common in pediatric patients. Sex, history of perinatal events, and presence of significant comorbid medical conditions are significant risk factors for developing communication disorders. Parents’ awareness of communication development is poor, and pediatricians need to be more aware of communication development assessment, management plan of communication disorders, and referral indications.
  646 100 -
Bacterial healthcare-associated infection rates among children admitted to Pediatric Intensive Care Unit of a Tertiary Care Hospital, Egypt
Azza A Moustafa, May M Raouf, Mona S El-Dawy
September-December 2017, 30(3):100-107
DOI:10.4103/AJOP.AJOP_2_18  
Background Healthcare-associated infections (HAIs) are life-threatening complications especially in pediatric ICU (PICU). Objective This study aimed to calculate the incidence of HAIs and device-associated infections (DAIs), as well as HAIs and DAI incidence density rate in a Alexandria University Children Hospital PICU, Egypt. Patients and methods A prospective cohort study was carried out over a period of 1 year. Personal, clinical, and laboratory data were recorded. HAIs were identified according to Centers for Disease Control and Prevention and National Healthcare Safety Network CDC/National Health Surveillance Network case definitions. Standard microbiological techniques were adopted. Results A total of 195 patients (of 282 admissions) who stayed more than 48 h in PICU were included. Overall, 16 patients developed bacterial HAIs, with a total of 25 episodes. HAIs incidence rate was 12.8/100 PICU admissions and incidence density was 15.6/1000 PICU days. All HAIs detected were DAI. Ventilator-associated pneumonia accounted for 72%, followed by central line (CL)-associated bloodstream infections at 24% and catheter-associated urinary tract infections at 4%.The rates of the DAI per 1000 device days were as follows: ventilator-associated pneumonia 12.4/1000 ventilator days, CL-associated bloodstream infections 4.2/1000 CL days, and catheter-associated urinary tract infections 0.69/1000 urinary catheter days. Gram negative bacteria were the most common isolated pathogens (n=18/25, 72%). All isolates were multidrug-resistant organisms. Conclusion and recommendations HAIs and DAI incidence rates in the current study were close to those of developed countries and lower than those of developing countries. Presence of an invasive device has a high risk for acquiring HAIs, resulting in higher mortality. The key to prevent HAIs is continuous education of infection prevention and control practices including an adoption of a surveillance program.
  557 97 -
Role of brain-type natriuretic peptide in rapid diagnosis and prognosis of persistent pulmonary hypertension of the newborn
Mohamed T Abdel latif, Bahaa S Hammad, Neveen L Mikhael, Mary E Elmirahem
January-April 2017, 30(1):11-16
DOI:10.4103/AJOP.AJOP_3_17  
Objective The diagnosis of persistent pulmonary hypertension of the newborn (PPHN) can often be difficult to make, especially in a clinical setting in which pediatric echocardiography is not readily available. This study aims at investigating the value of plasma brain-type natriuretic peptide (BNP) level as a noninvasive test in the diagnosis, prognosis, and differentiation of PPHN from other respiratory diseases in newborns with respiratory distress (RD). Patients and methods We used a prospective cohort study with three groups. One group was diagnosed with PPHN by clinical and echocardiographic criteria (PPHN group: n=20). The second group had been diagnosed with respiratory disease; however, PPHN was ruled out by having no evidence of elevated pulmonary pressure by echocardiography (RD group: n=20). The third group had no respiratory disease and was breathing room air (RA group: n=20). Plasma BNP levels were measured by Ray Bio BNP Enzyme Immunoassay Kit at study entry for all groups and upon recovery for PPHN cases. Results There was no difference between groups regarding gestational age, postnatal age, sex, birth weight, and mode of delivery. Initial BNP levels (pg/ml) were significantly elevated in the PPHN group relative to both the RA and RD groups. There was no difference in the initial plasma BNP level between the RD and RA groups. Plasma BNP levels declined significantly in the PPHN group upon recovery. Plasma BNP levels correlated with the gradient of the tricuspid regurgitation jet and the mean pulmonary artery pressure. Plasma BNP levels were higher, although insignificant, in PPHN because of underdevelopment. The mean plasma BNP level in septic babies was higher; however, this was insignificant, still the number of cases was low (two cases). Conclusion Plasma BNP levels were elevated in infants with PPHN but not in infants with other forms of RD. Follow-up plasma BNP level showed significant decline after recovery of PPHN cases. Elevated plasma BNP levels in term or near-term infants with RD should increase the suspicion of PPHN.
  492 91 -
Incidence of cardiac arrhythmia in children with dilated cardiomyopathy
Ali M Abd El Mohsen, Manal A Antonios, Mohamed M Elbiomy
January-April 2017, 30(1):32-36
DOI:10.4103/AJOP.AJOP_7_17  
Background To date, no study has accurately characterized the frequency of arrhythmia in children with dilated cardiomyopathy (DCM). Recent studies have reported that children with DCM are at a higher risk for life-threatening arrhythmias than was previously appreciated. Aim This study attempted to assess the incidence of and to identify the risk for life-threatening arrhythmias in children with DCM. Patients and methods All patients with DCM who were attending the cardiology clinic in Alexandria University Children’s Hospital were enrolled in the study. All data about demographics, presenting symptoms at time of diagnosis and medications were collected. Clinical, echocardiographic and ECG parameters, and 24-h Holter records of the patients were evaluated. Results Six patients experienced arrhythmia, representing a rate of 20.7%, with more prevalence among female patients. Only one patient experienced life-threatening arrhythmia (supra-ventricular tachycardia, SVT), representing a rate of 3.4%. Significant risk factors of arrhythmias were disturbed electrolytes levels (P=0.008), abnormal diagnostic left ventricular dimensions (P=0.006) and longer QRS duration (P<0.001). Conclusion Wider-scale studies should be conducted to further evaluate the role of patient’s age, age at diagnosis of DCM and diagnostic echocardiographic variables on the incidence of arrhythmia. The high incidence of arrhythmia associated with prolonged QRS duration should undergo further investigation.
  481 83 -
Intervention program to improve feeding, swallowing, and nutritional problems in children with cerebral palsy
Omneya M Omar, Mona Khalil, Hayam M Abd El-Ghany, Aya M Abdallah, Tarek E.I Omar
September-December 2017, 30(3):85-93
DOI:10.4103/AJOP.AJOP_22_17  
Background Most children with cerebral palsy (CP) have feeding problems, which lead to long-term malnutrition and respiratory disease, decreasing the quality of life of children and caregivers and causing early mortality. In developed countries with sufficient resources, high-cost and low-cost medical interventions, ranging from gastrostomy tube feeding to parent training, are available. In Egypt, the former is not widely available, and the latter is both scarce and its effectiveness not evaluated. Aim The study aimed to design and implement a training program to evaluate the effectiveness of a training program, to improve the feeding practices of caregivers of children with CP, to observe the effect on the level of nutritional status, feeding skills, and distress caused during feeding. Patients and methods From Alexandria University Children’s Hospital and its outpatient clinics (neurology and physical medicine), 20 caregivers and their children aged 1–5 years with moderate-severe CP (Gross Motor Fine Classification System III–V) and feeding difficulties were invited to a 10-session training program over 5 days (two sessions/day). Before and after training measures (quantitative and qualitative) were taken during the evaluation session of all children in addition to giving brief advice for caregivers, and follow-up for 3 months was done to evaluate the effect of education on performance and skills of the caregivers. Results The percentage of children with appropriate feeding position was significantly higher in final evaluation (66.7%) compared with preliminary evaluation (5%), and the median meal time was significantly shorter in final evaluation (42.5 min) compared with preliminary evaluation (60 min). The percentage of children and their caregivers gaining new feeding skills was significantly higher in final evaluation (38.9%) compared with preliminary evaluation (0%) (P=0.016). The percentage of children using the utensils appropriately was significantly higher in final evaluation (66.7%) compared with preliminary evaluation (15%) (P=0.004). There was no significant difference in the number of feeding problems, eating and drinking ability classification system level, and the mean weight for age Z score between studied children in preliminary and final evaluations. Conclusion The training program has a beneficial effect on improving feeding practices of children with CP and their caregivers after ten training sessions, with positive consequences for both child and caregiver. Methods of providing cheap food supplementation need to be studied, and further steps must be taken to ensure that services have the motivation and capacity to address this area of need.
  460 102 -
Impact of pre-pediatric ICU management on prognosis of sepsis and septic shock at Alexandria University Children’s Hospital
Hassan A El-Kinany, Amel A.A Mahfouz, Lamiaa E Abd El-Fattah
January-April 2018, 31(1):14-21
DOI:10.4103/AJOP.AJOP_9_18  
Background Pre-pediatric ICU (PICU) management in cases of severe sepsis and septic shock is an extremely important factor in the outcome of the patients. Pre-PICU management can also be the direct cause of better outcome of cases with severe sepsis and septic shock. Aim The purpose of this study was to evaluate the pre-PICU management in cases of severe sepsis and septic shock at Alexandria University Children’s Hospital and its association with the survival rate of the cases. Patients and methods A cross-sectional study was conducted on 40 patients during 12 months period at PICU of Alexandria University Children’s Hospital with the diagnosis of severe sepsis and/or septic shock. Their age ranged from 1 month to 12 years, 21 were males and 19 were females. All cases were subjected to history taking stressing on time from the start of illness until the patient arrived to the hospital, pre-referral treatment, number and kind of medical centers that took care of the patient before admission. The clinical condition of the patient on admission was evaluated (with respect to the degree of sepsis) and the mortality probability on admission was performed using Pediatric Index of Mortality 2 (PIM-2) score. Routine investigations were done at admission. Follow-up of the cases in PICU was evaluated by PIM-2 score, length of stay and the prognosis of cases whether improvement or death. Results Twenty-three (57.5%) cases presented with septic shock and 17 (42.5%) cases presented with severe sepsis. Gastrointestinal tract infection and chest infection were the most common clinical sources of sepsis (16 and 10 cases, respectively). The mean of the duration from start of illness until patient arrived to the hospital was 7 days in nonsurvivors versus 3 days in survivors. Eighteen (45%) patients did not receive any antibiotic therapy before admission, whereas 22 (55%) received antibiotics via different routes before admission. Conclusion The results indicated that gastrointestinal tract infections and chest infection were the most common clinical sources of sepsis. Administration of intravenous antimicrobial therapy with the onset of sepsis is an important factor in better prognosis of septic shock and PIM-2 score is a good predictor of mortality on the first day of admission to PICU. Referral from a tertiary hospital to PICU is a good indicator for better prognosis.
  457 85 -
Studying a possible relationship among serum leptin, serum zinc and BMI in children
Lamia M Hafez, Manal M.Abd El-Gawad, Ola H Elgaddar, Amenh B Yousif
January-April 2018, 31(1):1-7
DOI:10.4103/AJOP.AJOP_7_18  
Background Developing countries are facing the double burden of nutritional transition, malnutrition and micronutrient deficiencies, as well as a rapidly growing epidemic of childhood obesity. Leptin is a key hormone in the regulation of BMI, and a relation between zinc and leptin was detected. Aim This study aimed to investigate the relationship among serum leptin, serum zinc and BMI in children. Patients and methods A cross-sectional study was carried out on a total of 82 children of both sexes aged from 2 to 14 years attending the outpatient clinic at Alexandria University Children’s Hospital, Egypt, over 3 months from September 2016 to November 2016. All participants were clinically evaluated for weight, height and BMI. Serum leptin and serum zinc were measured. Results From the total sample of 82 children, it was found that the high percent of overweight children were found in the age group between 9 and at least 14 in both sexes (48% in boys and 37.5% in girls). The mean serum leptin level was insignificantly higher in girls in the age group from 9 to up to 14 years; it was 10.67 μg in girls, whereas it was 9.0 in boys. There was no significant difference in serum zinc level between boys and girls at all age groups. There was an insignificant negative correlation between serum leptin and serum zinc in boys and girls at all age groups. The correlation between serum leptin and BMI was significantly positive in girls at age group 9 to up to 14 years (r=0.644, P=0.013). Serum zinc was insignificantly negatively correlated with BMI in boys and girls at age group 9 to up to 14 years, but the relation was positively significant in boys in the age group 2 to less than 3 (r=0.757, P=0.049). Conclusion The correlation between leptin and BMI in girls was significant at age group 9 to up to 14 years. A negative insignificant correlation was found between serum leptin and serum zinc. Insignificant positive correlation was found between serum zinc and BMI.
  449 82 -
Prevalence of latent pulmonary tuberculosis in children with diabetes mellitus attending a Tertiary Care Hospital in Mansoura: a cross-sectional study
Mahmoud M Bakr, Ashraf A Elsharkawy, Yahya M Wahba, Nermin Y Abo Elkheir
September-December 2017, 30(3):94-99
DOI:10.4103/AJOP.AJOP_23_17  
Aims Tuberculosis (TB) and diabetes mellitus are closely associated with each other. We conducted a cross-sectional study to assess the prevalence and pattern of latent pulmonary TB in diabetic children using a combined screening tool. Settings and design A cross-sectional study was carried out in a Tertiary Care Hospital, Mansoura, Egypt, during the period from January to December, 2016. Materials and methods The study enrolled all diabetic children with the inclusion criteria who were available during the study period and attending the endocrinology outpatient clinics or admitted in the inpatient ward. A total of 70 diabetic patients completed tuberculin skin test (TST) reading, and their results were compared with those of 70 healthy controls. All patients were subjected to detailed medical history, complete physical examination, and laboratory and radiological evaluation. TB screening was done for both groups using TST, sputum microscopy and culture, and chest radiography. We used TST induration diameter more than 6 mm as the cut-off value to determine test positivity. Results A total of 53 (75.7%) patients of the studied diabetic group were poorly controlled. TST was positive in 30% of the screened diabetic patients. Test positivity was significantly higher among diabetic group when compared with control group. TST positivity was significantly higher in poorly controlled diabetic cases. There was a statistically significant negative correlation between TST induration diameter and HBA1C. Conclusion Diabetic patients are more vulnerable to latent pulmonary TB. The association between poor glycemic control and latent pulmonary TB among diabetic patients was evident. Combining TST with sputum culture and chest radiography did not improve screening results.
  393 79 -
Short-term prognostic value of serum cardiac troponin I levels in neonates with perinatal asphyxia
Mohamed H Gouda, Bahaa S Hammad, Mohamed A Amen
September-December 2017, 30(3):108-119
DOI:10.4103/AJOP.AJOP_3_18  
Background Neonatal hypoxic–ischemic encephalopathy (HIE) is a neonatal brain injury caused by perinatal asphyxia and is a major cause of neonatal morbidity and mortality. Cardiac dysfunction forms a part of the clinical spectrum of multiorgan dysfunction in asphyxiated newborns. The more cardiac dysfunction the patients have, the more severe encephalopathy they would suffer. Cardiac troponin I (cTnI) is one of neonatal HIE-related biomarkers that can aid the diagnosis of perinatal asphyxia and anticipate the severity of associated myocardial dysfunction. Aim The current study was designed to assess the serum cTnI concentration and to evaluate its short-term prognostic value in newborns with HIE. Patients and methods The present study is a prospective observational study conducted on 100 full-term newborn infants in the period from May 2016 to May 2017. Enrolled newborns were divided into two groups: the case group (50 full-term newborn infants with evidence of perinatal asphyxia) and the control group (50 full-term newborn infants without evidence of perinatal asphyxia). Quantitative estimation of serum cTnI concentrations was done in all enrolled newborns within 12 h of birth using direct chemiluminometric technology performed on ADVIA Centaur Immunoassay System (TnI-Ultra). Serum levels of creatine kinase-MB (CK-MB) were also measured to assess its sensitivity and specificity as a marker of perinatal asphyxia. Additionally, echocardiography was done to exclude structural heart diseases. Left ventricular fractional shortening (LVFS) was also measured to assess cardiac involvement. Results Serum concentrations of cTnI were statistically significantly higher among the case group when compared with the control group. Additionally, serum levels of cTnI were found to increase with increasing severity of HIE. Serum levels of CK-MB were also statistically higher among the case group. However, pairwise statistical comparison of serum CK-MB concentrations in different stages of HIE revealed no statistical significant difference. No statistical significant difference was found between the two studied groups regarding LVFS. Moreover, LVFS did not differ significantly between the different stages of HIE. Among the different markers of myocardial dysfunction assessed in the current study, cTnI was found to be the most sensitive and specific predictor of poor short-term outcome in newborns with perinatal asphyxia. When comparing serum concentrations of cTnI and CK-MB in both surviving and nonsurviving newborns in the asphyxia group, it was found that serum concentrations of cTnI were statistically significantly lower in the group of survivors. In contrast, there was no statistical significant difference regarding serum concentrations of CK-MB between surviving and nonsurviving asphyxiated newborns. Conclusion Serum concentrations of cTnI were elevated in asphyxiated newborns with respect to healthy infants and increase with increasing severity of HIE. cTnI can also be used as an excellent early predictor of mortality in newborns with perinatal asphyxia.
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Psychometric properties of a translated arabic version of cerebral palsy-quality of life questionnaire: primary caregiver form
Heba M.T El-Weshahi, Mona K Mohamed, Hayam M Abd-Elghany, Tarek E.I Omar, Alaa E Azzawi
May-August 2017, 30(2):53-60
DOI:10.4103/AJOP.AJOP_15_17  
Background In the context of child rehabilitation, quality of life (QOL) is an important health-related outcome measure that has a great clinical utility as it can guide practice. Study objectives The aim of this study was to develop a translated Arabic version of primary caregiver form of cerebral palsy QOL questionnaire for children aged 4–12 years (CP QOLـChild) and to assess its validity and reliability to be readily used in Arabic and Egyptian cultures. Patients and methods The original English version of CP-QOL questionnaire was translated into Arabic language using forward–backward translation method, and then a cross-sectional survey was conducted including 200 children with cerebral palsy aged 4–12 years and their caregivers. Caregivers of children were interviewed to collect data about their demographic characteristics, age, and sex of their children. They were asked to fill the translated Arabic version of QOL questionnaire. Assessment of psychometric properties including test–retest reliability, internal consistency, and item internal consistency was conducted. Results The translated questionnaire showed excellent test–retest reliability and good internal consistency as the intraclass correlation ranges from 0.88 to 0.97 and Cronbach’s α exceeds 0.7 except for the domains of family health and emotional well-being. The majority of the items have moderate to good correlation with their domain scores. Four out of seven domains showed significant correlation with Gross Motor Function Classification System. Conclusion The translated Arabic version of CP-QOL questionnaire (caregiver form) is valid and reliable and could be used to assess quality of life of children with cerebral palsy in Arab-speaking population.
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Risk factors for febrile seizures in Benghazi, Libya: a case–control study
Amenh B Yousif, Lamia M Hafez, Fatma S Benkhaial
May-August 2017, 30(2):68-73
DOI:10.4103/AJOP.AJOP_21_17  
Background Febrile seizures (FS) are the most common seizures of childhood, occurring in 2–5% of children at 6 months to 5 years of age. The risk factors for FS include developmental delay, delayed discharge from the neonatal ICU, viral infections, a family history of FS, possibly iron deficiencies, and nonexclusive breastfeeding. Aim This study was carried out to identify and quantify the risk factors for FS in Libyan children. Patients and methods A case–control study was carried out including one hundred patients with FS aged 6–60 months, admitted to Benghazi Paediatrics Hospital, Libya, who were matched with another 100 children with fever, but without seizure of the same age as the control group. The control group was enrolled randomly and the study was carried out over 8 months from 1 October 2016 to 31 May 2017. Data were collected using a pretested questionnaire. Blood samples were collected from both cases and controls and a complete blood count was performed. χ2-Test was used to assess the significance of the risk factors. Univariate and multivariate logistic regression analyses were carried out to determine the strength of associations at a 5% level of significance. Results The majority of cases and the children in the control group were between 6 months and less than 25 months of age. It was found that 93% of the cases and 87% of the children in the control group had a temperature higher than 38°C. The most common types of FS for cases were simple FS, which was recorded in 86% of cases, and complex FS, recorded in 14% of cases. A positive family history of FS was reported in 48% of cases compared with 22% of the children in the control group [odds ratio (OR)=3.27, 95% confidence interval (CI): 1.77–6.05, P<0.001]. Iron-deficiency anemia was reported in 73% of cases compared with 33% of controls, and this was found to be a strong significant risk factor for FS (OR=5.48, 95% CI: 2.99–10.07, P<0.001). Furthermore, nonexclusive breast-feeding was reported in 66% of cases compared with 32% of controls (OR=4.12, 95% CI: 2.28–7.43, P<0.001); prematurity was reported in 29% of cases compared with 11% of children in the control group (OR=3.30, 95% CI: 1.54–7.07, P<0.001). Conclusion The results of the present study indicated that iron-deficiency anemia, nonexclusive breast-feeding, and a family history of FS and prematurity were the most important risk factors for FS. This study recommends educational programs for modifiable risk factors, encourages exclusive breast feeding in the first 6 months, and early diagnosis and treatment for iron-deficiency anemia in children.
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Organizational skills training, neurofeedback, and/or pharmacotherapy in the treatment of school-aged children with attention-deficit hyperactivity disorder
Hanan G Azouz, Faten I Abdel Latif, Tarek E.S Omar, Mona Khalil, Marwa S Abdel Maksoud
May-August 2017, 30(2):61-67
DOI:10.4103/AJOP.AJOP_18_17  
Background Attention deficit hyperactivity disorder (ADHD) is the most common developmental and neurobehavioral disorder in childhood. It is characterized by hyperactivity, impulsivity, and/or inattention. Objective To study the efficacy of implementation of different interventional modalities including medication (MED; atomoxetine) either alone or in combination with behavioral therapy (organization skills training; OST) or cognitive training (neurofeedback training; NFT) in alleviation of the core symptoms of ADHD and its comorbid conduct problem among school-aged children with ADHD. Participants and methods This was a multigroup design study with preassessment and postassessment with the Arabic form of Conners’ Parent Rating Scale short form (CPRS-48). Participants were 45 school-aged children (age range from 6 to 10 years) with a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria. Children were recruited from the Pediatric Behavioral Outpatient Clinic of Alexandria University Children Hospital, Alexandria, Egypt, and they were allocated into the groups: group OST and MED (n=15); group NFT and MED (n=15); and group MED (n=15). Results Combined OST and MED showed a significant decrease in hyperactivity/impulsivity (P=0.011) and comorbid conduct problem scores (P=0.030) on postinterventional assessment with CPRS-48. However, no statistically significant difference was found among the other studied groups, groups NFT and MED or group MED, either on ADHD core symptoms or its comorbid conduct problem. Conclusion Combined OST and MED showed significant efficacy in the alleviation of ADHD core symptoms and comorbid conduct problem.
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Disseminated intravascular coagulation scoring in children with newly diagnosed acute leukemia
Hoda M.A Hassab, Mostafa A.S Salama, Wessam M El Gendy, Yasmine F El Chazli
January-April 2018, 31(1):22-33
DOI:10.4103/AJOP.AJOP_10_18  
Background Patients with acute leukemia (AL) commonly present with abnormalities in laboratory tests of blood coagulation. Coagulation abnormalities and disseminated intravascular coagulation (DIC) have been extensively studied in acute promyelocytic leukemia, but only a limited number of studies addressed this issue in children with other types of AL. Objective The aim of this study was to detect DIC by using the International Society of Thrombosis and Haemostasis scoring system, for both nonovert and overt DIC, among newly diagnosed children with AL. Participants and methods The study was a diagnostic test accuracy study including 25 children presenting with newly diagnosed AL (lymphoblastic and myeloid) and admitted to the Hematology–Oncology Unit at Alexandria University Children’s Hospital. They were consecutively recruited between October 2016 and March 2017. Coagulation studies including prothrombin time, D-dimer, fibrinogen, antithrombin III, and protein C levels were assessed, and the International Society of Thrombosis and Haemostasis scoring system was used for defining nonovert and overt DIC. Results The age of patients included in the present study ranged from 17 to 149 months, with a median of 48 months; males and females were almost equally represented. At baseline assessment, 10 (40%) of 25 patients had a positive overt DIC score and only seven (28%) of 25 had a positive nonovert DIC score. Bleeding manifestations were a common problem in the present study, as 16 (64%) patients presented with bleeding symptoms, being more frequently in patients with an overt DIC positive score (P=0.040). The median platelet count (P=0.023), D-dimer level (P=0.000), and fibrinogen level (P=0.010) showed a significant statistical difference between patients with either positive or negative overt DIC score, whereas neither white blood cells count, absolute blasts count, hemoglobin, prothrombin time, antithrombin III nor protein C levels did. Conclusion Our data confirm that children with AL have some hemostatic derangement at baseline. A positive overt or nonovert DIC score was not statistically related to a worse end of induction remission status or a significantly higher 28-day mortality rate. Larger multicenter studies are needed to determine the most clinically relevant hemostatic abnormalities and adapt more sensitive and specific scoring system for DIC in children with hematological malignancies.
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Prevalence, determinants, and health service utilization of ‘at risk’ under-five children attending a Family Health Center, Egypt 2017
Eman A Sultan, Nagwa F Shokair, Karima M Teba
January-April 2018, 31(1):34-41
DOI:10.4103/AJOP.AJOP_11_18  
Background More than half of under-five child deaths are due to the diseases that are preventable and treatable through simple and affordable interventions. Owing to lack of resources, all under-five cannot be given equal time and attention. Therefore, ‘at risk’ concept has gained importance where health care is provided to all children., whereas children with high risk are given special attention. Aim This study aims to determine the prevalence and identifying determinants of ‘at risk’ under-five children attending Rasheed Family Health Center and to determine the pattern of utilization of available health services. Participants and methods This cross-sectional study included 300 under-five children with their mothers. Data were collected using an interviewing questionnaire including personal-social characteristics, obstetric history, and child characteristics. ‘At risk’ children were identified based on the recommendations of WHO Expert Committee and accordingly, the ‘at risk’ group was compared with those ‘not at risk’. Results Results show that the prevalence of ‘at risk’ children among the studied group was 77.7%. The most frequent risk factors were recurrent or chronic gastrointestinal and/or respiratory tract infections followed by delay in receiving supplementary feeds, birth spacing less than 2 years and early lactation failure. Formula feeding and attacks of gastroenteritis were significant predictors of ‘at risk’ children. The main factors behind low utilization of the services were the long distance between home and the center, unpaved roads, and high costs of transportation, health care service, and medications.
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Short-term outcome of patent ductus arteriosus in the neonatal period
Salah R Zaher, Manal A.M Antonios, Adham O Badib, Mahmoud M.B Nadder
January-April 2018, 31(1):8-13
DOI:10.4103/AJOP.AJOP_8_18  
Background Patent ductus arteriosus (PDA) is a common problem in neonates. It has a very high incidence especially in infants weighing 1000 g or less reaching in some studies up to 60%. Aim The current study aimed at assessing the short-term outcome of PDA in the first 28 days of neonatal life. Patients and methods All neonates admitted to Alexandria University Children’s Hospital Newborn unit at El-Shatby were assessed (n=410). Two-hundred fifty were preterm and 160 were term. Sixty cases were proved by echocardiography to have PDA at day 4 including 47 preterm and 13 term neonates who were followed up at day 10 and day 28 to assess the outcome of PDA. Results The incidence of PDA was 18.8 and 8.1% in the preterm and in the term babies, respectively. The incidence in preterm neonates 32 weeks of gestational age or less was 29.1% and in neonates weighting 1000 g or less was 36.6%. It was also noted that the lower the gestational age and birth weight, the higher the incidence of PDA. Females were more common to have PDA in the term group. On following up these cases, the closure rate at 10 days was 62.2% in the preterm in comparison with 61.5% in the term, but at 28 days, the closure rate was 94.4% in the preterm in comparison with 66.7% in the term. Ten cases were not given any medical treatment and their closure rate was 70%, and no cases developed heart failure. It was also noticed that the closure rate is higher in cases that received ibuprofen (72%) in comparison with paracetamol (60%) at the age of 10 days. Conclusion PDA in the neonatal period is a very common cardiac malformation that frequently closes spontaneously. The rate of closure is higher among preterm, low-birth-weight and small-for-gestational-age babies.
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