Publications by authors named "Qalab Abbas"

32 Publications

Multisystem inflammatory syndrome (MIS-C) in Pakistani children: A description of the phenotypes and comparison with historical cohorts of children with Kawasaki disease and myocarditis.

PLoS One 2021 21;16(6):e0253625. Epub 2021 Jun 21.

Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States of America.

Objectives: To determine clinical, laboratory features and outcomes of Multisystem Inflammatory Syndrome in children (MIS-C) and its comparison with historic Kawasaki Disease (KD) and Viral Myocarditis (VM) cohorts.

Methods: All children (1 month- 18 years) who fulfilled the World Health Organization criteria of MIS-C presenting to two tertiary care centers in Karachi from May 2020 till August 31st were included. KD and VM admitted to one of the study centers in the last five years prior to this pandemic, was compared to MIS-C.

Results: Thirty children with median age of 24 (interquartile range (IQR)1-192) months met the criteria for MIS-C. Three phenotypes were identified, 12 patients (40%) with KD, ten (33%) VM and eight (26%) had features of TSS. Echocardiography showed coronary involvement in 10 (33%), and moderate to severe Left Ventricular dysfunction in 10 (33%) patients. Steroids and intravenous immunoglobulins (IVIG) were administered to 24 (80%) and 12 (41%) patients respectively while 7 (23%) received both. Overall, 20% children expired. During the last five years, 30 and 47 children were diagnosed with KD and VM, respectively. Their comparison with MIS-C group showed lymphopenia, thrombocytosis, and higher CRP as well as more frequent atypical presentation in MIS-C KD group with less coronary involvement. The MIS-C VM was more likely to present with fulminant myocarditis.

Conclusions: Our MIS-C cohort is younger with higher mortality compared to previous reports. MIS-C is distinct from historic cohorts of KD and VM in both in clinical features and outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253625PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216534PMC
June 2021

Comparative Analysis of Pediatric COVID-19 Infection in Southeast Asia, South Asia, Japan, and China.

Am J Trop Med Hyg 2021 Jun 15. Epub 2021 Jun 15.

Duke-NUS Medical School, Singapore.

There is a scarcity of data regarding coronavirus disease 2019 (COVID-19) infection in children from southeast and south Asia. This study aims to identify risk factors for severe COVID-19 disease among children in the region. This is an observational study of children with COVID-19 infection in hospitals contributing data to the Pediatric Acute and Critical Care COVID-19 Registry of Asia. Laboratory-confirmed COVID-19 cases were included in this registry. The primary outcome was severity of COVID-19 infection as defined by the World Health Organization (WHO) (mild, moderate, severe, or critical). Epidemiology, clinical and laboratory features, and outcomes of children with COVID-19 are described. Univariate and multivariable logistic regression models were used to identify risk factors for severe/critical disease. A total of 260 COVID-19 cases from eight hospitals across seven countries (China, Japan, Singapore, Malaysia, Indonesia, India, and Pakistan) were included. The common clinical manifestations were similar across countries: fever (64%), cough (39%), and coryza (23%). Approximately 40% of children were asymptomatic, and overall mortality was 2.3%, with all deaths reported from India and Pakistan. Using the multivariable model, the infant age group, presence of comorbidities, and cough on presentation were associated with severe/critical COVID-19. This epidemiological study of pediatric COVID-19 infection demonstrated similar clinical presentations of COVID-19 in children across Asia. Risk factors for severe disease in children were age younger than 12 months, presence of comorbidities, and cough at presentation. Further studies are needed to determine whether differences in mortality are the result of genetic factors, cultural practices, or environmental exposures.
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http://dx.doi.org/10.4269/ajtmh.21-0299DOI Listing
June 2021

Acute Symptomatic Seizures in Critically Ill Children: Frequency, Etiology and Outcomes.

J Pediatr Neurosci 2020 Oct-Dec;15(4):375-378. Epub 2021 Jan 19.

Department of Pediatrics and Child Health, Aga Khan University Karachi, Karachi, Pakistan.

Background: Critically ill individuals have an increased risk of acute symptomatic seizures secondary to systemic illnesses; unrecognized or untreated seizures can quickly convert into status epilepticus, which is associated with high morbidity and mortality.

Objective: The aim of this study was to determine frequency, etiology, and outcome of seizures in critical ill children admitted in intensive care unit of a tertiary care hospital.

Materials And Methods: Retrospective review of medical records of all children admitted in pediatric intensive care unit (PICU) of the Aga Khan University from January 2016 to December 2018 and who had a new-onset seizure irrespective of underlying diagnosis was carried out after ethical review committee approval. Data were collected on a structured proforma; it included demographic information as well as relevant clinical and outcome information. The data were analyzed on Statistical Package for the Social Sciences (SPSS) software program, version 19.0. The descriptive statistics frequency and percentage was computed for qualitative variable. Mean and standard deviation were computed for quantitative variable, and univariate analysis was performed.

Results: During the study period, a total 2053 patients were admitted in the PICU. One hundred six (5%) had seizure. Sixty-three (59.5%) were males. Meningitis 21 (20%), sepsis 21 (20%), complicated pneumonia 18 (17%) were the major primary diagnosis in these children. Mean age of the study population was 75 months (standard deviation [SD] ± 54.4) and 72 (68%) were <5 years of age, whereas 63 (59.5%) were males. The seizures lasted >10min in 10 (10%) and were associated with high had neurological deficit ( = 0.001). We did not observe any correlation with electrolyte imbalance, renal failure, need of ventilator support with duration of seizure, and type of seizure ( > 0.005).

Conclusion: Infection was the most common etiology associated with a new-onset seizure in children admitted in our PICU. Seizures lasting for >10min were observed with high neurological deficit. We did not find any association of mortality with seizure duration.
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http://dx.doi.org/10.4103/jpn.JPN_140_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078641PMC
January 2021

High Flow Nasal Cannula Therapy in Children with Acute Respiratory Insufficiency in the Pediatric Intensive Care Unit of a Resource-limited Country: A Preliminary Experience.

J Coll Physicians Surg Pak 2021 Jan;31(1):110-112

Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan.

A retrospective study was performed in children (aged one month - 16 years) receiving HFNC to determine the frequency, efficacy and adverse effects of high flow nasal cannula (HFNC) therapy in the pediatric intensive care unit (PICU), from January to December 2017. Treatment failure was defined as clinical deterioration on HFNC therapy such that mechanical ventilation (MV) was required. Clinical parameters before and after HFNC were assessed using repeated measures analysis of variance. A total of 120 patients received HFNC therapy (21% of total admissions). Primary diagnosis were respiratory disease (50%), central nervous system diseases (14.2%), sepsis (10.8%), and postoperative care (10%). Mean duration of HFNC was 27.5 ±19.7 hours and mean PICU length of stay was 6 ± 6 days. Pneumothorax developed in four patients. MV was required in 28 patients, and subsequently, 15 deaths occurred in that group. HFNC is a frequently used, safe and effective therapy for children requiring respiratory support in PICU. Key Words: Respiratory insufficiency, Non-invasive ventilation, Paediatric intensive care unit.
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http://dx.doi.org/10.29271/jcpsp.2021.01.110DOI Listing
January 2021

Abstract to publication conversion in pediatric critical care medicine in Pakistan.

Acute Crit Care 2021 Feb 5;36(1):62-66. Epub 2021 Feb 5.

Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.

Background: To determine the rate of conversion of abstracts presented at conferences into full-text articles published in peer-reviewed journals in the field of pediatric critical care medicine (PCCM) in a developing country.

Methods: We retrospectively reviewed PCCM abstracts from Pakistan presented at national and international pediatric and critical care conferences over 10 years (January 2010 to March 2020). Data included abstract characteristics, such as presentation (poster/oral), presenter (fellow/resident), time of meeting (month and year), type of meeting, study design and topic; and publication characteristics, such as journal name, time (month and year) and first author. The primary outcome was publication rate of PCCM abstracts presented in meetings and time (months) from presentation to publication.

Results: A total of 79 PCCM abstracts were presented in 20 meetings during the study period. There were 65 poster presentations (82.28%), of which 63 (79.74%) were presented at international critical care conferences and all presenters were PCCM fellows. In total, 64 (81%) abstracts were descriptive observational studies (retrospective: 50, 63.29%) and prospective (14, 17.72%). Only one was an interventional randomized controlled trial. The publication rate of PCCM abstracts was 63.3% (50/79) and the mean time to publication was 12.39±13.61 months. The publication rate was significantly correlated to the year of publication (P<0.001).

Conclusions: The PCCM abstract publication rate and mean time from presentation to publication was 63.3% and 12.39±13.61 months, respectively, in a developing country.
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http://dx.doi.org/10.4266/acc.2020.00780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940097PMC
February 2021

Laboratory Blood Testing In Paediatric Intensive Care Unit Of A University Hospital: Are We Doing It Appropriately?

J Ayub Med Coll Abbottabad 2020 Jul- Sep;32(3):421-423

Department of Pediatrics and Child Health, Aga Khan University Karachi, Pakistan.

Retrospective chart review of all children (aged-one month to 16 years) admitted in our paediatric intensive care from June to November 2016 was done to determine the indication of different laboratory tests. LBT indications were defined into: diagnostic/case findings/screening tests to make a diagnosis; haemostatic tests (to monitor function or identify before clinical signs and symptoms) and therapeutic /monitoring tests to get the level of drug directly or getting level of marker as a guide to therapy. Laboratory tests reports which were within normal range more than once were labelled as in-appropriate tests. In total 274 patients, Haemostatic tests were performed for mean of 35.18±56.72 times (range of 0-429), monitoring for mean of 9.38±20 times (range 0-165), and therapeutic tests (3.26±11.25). Most common tests included serum Sodium levels (7.83±12.73), Serum Potassium (8.19±12.80), bicarbonate (7.75±11.9). 13.40±9.11 tests were done on first day and 13.0±8.49/day tests were performed afterwards. Cumulatively 54.31±74.21 tests were performed/ patients out of which 18.5±37.82 were inappropriate.
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December 2020

Acute Kidney Injury after Congenital Heart Disease Surgery: A Single-Center Experience in a Low- to Middle-Income Country.

Cureus 2020 Apr 18;12(4):e7727. Epub 2020 Apr 18.

Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK.

Background Acute kidney injury (AKI) is a commonly recognized clinical problem after congenital heart disease (CHD) surgery. Increased perioperative morbidity, development of chronic kidney disease, and increased mortality are the major concerns. We investigated frequency, risk factors, and outcomes of AKI after CHD surgery at our hospital. Methods This study was a retrospective analytic review conducted from January 2013 to October 2016 on patients aged between 1 month and 45 years who underwent cardiopulmonary bypass (CPB) for CHD surgery. The modified Kidney Disease Improving Global Outcomes criteria based on serum creatinine value was adopted to diagnose AKI. We assessed AKI frequency and its staging, and outcomes as AKI resolution, length of stay, and mortality. Stages II and III (plasma creatinine level two or more times the baseline) were labeled as severe AKI. Univariate and multivariate logistic regression analyses were conducted, and results were reported as mean with standard deviation and as frequencies with percentage. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported for factors associated with the development of AKI. Results Of the 840 patients who underwent CHD surgery, 237 (28%) developed AKI. AKI stages II1 and III were seen in 101 (42%) and 103 (43%) patients, respectively. Prolonged CPB time > 120 minutes (adjusted OR [AOR]: 1.87; 95% CI: 1.22-2.88; p = 0.004) and hemoglobin > 16 gm/dL (AOR: 1.80; 95% CI: 1.16-2.78; p = 0.008) were associated with the development of AKI on multivariate analysis. AKI resolved spontaneously in 222 (94%) patients, and 10 (4%) patients who developed AKI died. Conclusions Most patients with AKI showed spontaneous resolution. Prolonged CPB time and increased hemoglobin were found to be significant risk factors. Our study found spontaneous resolution of AKI in most cases. However, preplanning and careful monitoring in patients with expected prolonged CPB time and increased baseline hemoglobin can prevent and identify AKI at an early stage.
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http://dx.doi.org/10.7759/cureus.7727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234068PMC
April 2020

Potentially Preventable Mortality in the Pediatric Intensive Care Unit: Findings from a Retrospective Mortality Analysis.

Cureus 2020 Mar 21;12(3):e7358. Epub 2020 Mar 21.

Pediatrics, The Indus Hospital, Karachi, PAK.

Objective The goal of this study was to estimate the proportion and causes of potentially preventable mortality among critically ill children admitted to the pediatric intensive care unit (PICU). Methods The medical records of all patients who died in the PICU (age range: one month to 16 years) between January 2014 and December 2015 were evaluated by two independent reviewers to determine whether there had been any delayed recognition of deteriorating conditions, delayed interventions, unintentional/unanticipated harm, medication errors, adverse reactions to transfusions, and hospital-acquired infections that could have resulted in unanticipated death. Preventability was labeled on a 6-point scale. Results During the study period, 92 of 690 patients did not survive [median age: 60 months, interquartile range (IQR): 114]. The median Pediatric Risk of Mortality (PRISM) III score was 17 (IQR: 6). Major diagnostic categories included sepsis (n = 29, 35%), central nervous system diseases (n = 16, 17%), oncological/hematological diseases (n = 6, 6%), cardiac diseases (n = 4, 4%), and miscellaneous conditions. None of the deaths had definitive or strong evidence of preventability. Four (4.3%) patients were in category 4 (i.e., possibly preventable, >50/50 chance), 15 (16.3%) in category 3 (possibly preventable, <50/50 chance), 28 (30.4%) had some evidence of preventability, and 45 (49.0%) were labeled as definitely not preventable. Late identification (diagnostic error) of the worsening condition in four (21.0%) patients, slow intervention in six (31.6.0%), and hospital-acquired infections in 10 (52.6%) were found to be related to potentially preventable mortality. Conclusions Preventable diagnostic errors and nosocomial infections (NIs) are major contributors to preventable mortality. Structured mortality analysis provides actionable information for future preventive strategies. Improvement in care processes, including clinical decision support systems, could help reduce preventable mortality rates.
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http://dx.doi.org/10.7759/cureus.7358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174862PMC
March 2020

Global burden of respiratory infections associated with seasonal influenza in children under 5 years in 2018: a systematic review and modelling study.

Lancet Glob Health 2020 04 20;8(4):e497-e510. Epub 2020 Feb 20.

Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.

Background: Seasonal influenza virus is a common cause of acute lower respiratory infection (ALRI) in young children. In 2008, we estimated that 20 million influenza-virus-associated ALRI and 1 million influenza-virus-associated severe ALRI occurred in children under 5 years globally. Despite this substantial burden, only a few low-income and middle-income countries have adopted routine influenza vaccination policies for children and, where present, these have achieved only low or unknown levels of vaccine uptake. Moreover, the influenza burden might have changed due to the emergence and circulation of influenza A/H1N1pdm09. We aimed to incorporate new data to update estimates of the global number of cases, hospital admissions, and mortality from influenza-virus-associated respiratory infections in children under 5 years in 2018.

Methods: We estimated the regional and global burden of influenza-associated respiratory infections in children under 5 years from a systematic review of 100 studies published between Jan 1, 1995, and Dec 31, 2018, and a further 57 high-quality unpublished studies. We adapted the Newcastle-Ottawa Scale to assess the risk of bias. We estimated incidence and hospitalisation rates of influenza-virus-associated respiratory infections by severity, case ascertainment, region, and age. We estimated in-hospital deaths from influenza virus ALRI by combining hospital admissions and in-hospital case-fatality ratios of influenza virus ALRI. We estimated the upper bound of influenza virus-associated ALRI deaths based on the number of in-hospital deaths, US paediatric influenza-associated death data, and population-based childhood all-cause pneumonia mortality data in six sites in low-income and lower-middle-income countries.

Findings: In 2018, among children under 5 years globally, there were an estimated 109·5 million influenza virus episodes (uncertainty range [UR] 63·1-190·6), 10·1 million influenza-virus-associated ALRI cases (6·8-15·1); 870 000 influenza-virus-associated ALRI hospital admissions (543 000-1 415 000), 15 300 in-hospital deaths (5800-43 800), and up to 34 800 (13 200-97 200) overall influenza-virus-associated ALRI deaths. Influenza virus accounted for 7% of ALRI cases, 5% of ALRI hospital admissions, and 4% of ALRI deaths in children under 5 years. About 23% of the hospital admissions and 36% of the in-hospital deaths were in infants under 6 months. About 82% of the in-hospital deaths occurred in low-income and lower-middle-income countries.

Interpretation: A large proportion of the influenza-associated burden occurs among young infants and in low-income and lower middle-income countries. Our findings provide new and important evidence for maternal and paediatric influenza immunisation, and should inform future immunisation policy particularly in low-income and middle-income countries.

Funding: WHO; Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S2214-109X(19)30545-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083228PMC
April 2020

Paediatric porphyria and human hemin: a treatment challenge in a lower middle income country.

BMJ Case Rep 2020 Jan 8;13(1). Epub 2020 Jan 8.

Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Here, we report a case of a 15-year-old girl who presented to the emergency department with symptoms of abdominal pain, nausea, vomiting and seizures. She was diagnosed with acute intermittent porphyria. Treatment was started by removing all porphogenic drugs, providing high glucose intake (oral and intravenous), which initially resulted in good clinical outcomes. However, she deteriorated again and also developed neurological manifestation (paraplegia) for which she required mechanical ventilation because of acute respiratory failure. This time she was initiated on human hemin for four consecutive days. After 2 days of therapy, her porphobilinogen levels decreased to 50% of the initial raised value. Increased lactic acid and blood urea nitrogen were the two side effects observed after the treatment, with no apparent signs of acute kidney injury. To the best of our knowledge, in paediatric population, this is the first reported case of treatment of acute intermittent porphyria with human hemin in Pakistan.
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http://dx.doi.org/10.1136/bcr-2019-232236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954746PMC
January 2020

OR to ICU handoff: theory of change model for sustainable change in behavior.

Asian Cardiovasc Thorac Ann 2019 Jul 12;27(6):452-458. Epub 2019 Jun 12.

2 Department of Surgery, Aga Khan University, Karachi, Pakistan.

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http://dx.doi.org/10.1177/0218492319850730DOI Listing
July 2019

Use of Interventional Radiology in Critically Injured Children Admitted in a Pediatric Intensive Care Unit of a Developing Country.

Cureus 2019 Jan 19;11(1):e3922. Epub 2019 Jan 19.

Radiology, Aga Khan University Hospital, Karachi, PAK.

Objective The aim of this study was to describe the outcome of the use of interventional radiological procedures (IRP) (angioembolization) in critically injured children. Methods A retrospective review of medical records of all children who underwent an IRP from January 2010 to December 2015 was done. Data were collected on a structured proforma and results are presented as mean with standard deviation and frequency with percentages. Result Eighteen patients were identified who underwent IRP during the study period. The mean age was 10.4 ± 4.3 years and 10 (55%) were males. Ten patients had a road traffic accident, four had a history of fall, one patient had glass cut pelvic injury, and two patients had blunt abdominal trauma, while one patient had bleeding secondary to hemipelvectomy. The genitourinary system was involved in five patients, liver in four, and spleen in two and pancreas in one patient. Bleeding was from branches of internal iliac artery in seven patients, hepatic artery in three patients, splenic artery in two patients, and middle colic artery in one patient, while one patient had blood oozing from the bone after hemi-pelvictomy. Four French vascular access sheath was placed under ultrasound guidance; this was followed by the placement of C1 catheter (Cordis, Miami, FL). After vessel identification, a 2.7F Progreat microcatheter (Terumo, Tokyo) was used for super-selective cannulation of the bleeding vessel. Intravascular coil, polyvinyl alcohol (PVA) particles, or gel foam was used for the embolization of bleeding vessels. No procedural complications were observed except minor oozing in one patient. One patient expired due to multiorgan dysfunction. Conclusion Angioembolization is a useful and relatively safe procedure in the management of vitally stable children with hemorrhagic abdominopelvic injuries. However, further studies may be needed to evaluate the efficacy and cost-effectiveness of this practice, especially in resource-constrained settings.
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http://dx.doi.org/10.7759/cureus.3922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426563PMC
January 2019

Ultrasonographic optic nerve sheath diameter Measurement for raised intracranial pressure in a Tertiary care centre of a developing country.

J Ayub Med Coll Abbottabad 2018 Oct-Dec;30(4):495-500

Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan.

Background: Intracranial hypertension is not an uncommon life-threatening syndrome, caused by a variety of non-neurological and neurological illnesses, and quick diagnosis, timely treatment of Raised Intracranial Pressure (ICP) is associated with improved outcome. Our aim of study was to determine ultrasonographic measurement of Optic nerve sheath diameter (ONSD) for raised ICP.

Methods: Prospective case series done in Emergency and Paediatric critical care unit of Aga Khan University Hospital. ONSD measurement in millimetres was done by placing linear probe of ultrasound on eye ball.

Results: Forty-eight patients were included in study with mean age of 7.5±5.0 years with 21/48 (43.8%) between 1-8 years and 19/48 (39.6%) >8 years with 32/48 (66.7%) were male. Non-traumatic coma was most common diagnosis 41/48 (85.4%) with infectious cause being most common while Traumatic brain injury constitutes 7/48 (14.6%). Ct scan brain was done in 39/48 (81.3%) while MRI brain in rest of patients. Raised ICP was found in 83.33% (40/48) patients with Ultrasonographic ONSD measurement as compared to CT scan/MRI 14/48 (29.2%). 85% of patients, showed ultrasonographic ONSD measurement suggestive of Raised ICP with GCS ≤12. Mean ONSD with signs of raised ICP in infants 4.64 (±0.48), in 1-10 years 6.44 (±0.65), and in adolescent >10 years 6.28 (±0.62) ONSD respectively with ROC Curve showing Area Under Curve (AUC) 0.814 ( 95% CI, 0.692-0.936).

Conclusions: We identified threshold of Ultrasonographic ONSD measurement in infants >4.0 mm, in children 1-10 yrs >4.71 mm, in adolescent >10 yrs >5.43 mm for raised ICP with sensitivity and specificity of 100% and 60-66.7% respectively. 85% of patients showed raised ICP with Ultrasonographic ONSD measurement with GCS ≤12.
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February 2019

Thrombolysis Using Tissue Plasminogen Activator: Experience from a Critical Care Setting.

Indian J Hematol Blood Transfus 2018 Oct 20;34(4):723-726. Epub 2018 Mar 20.

3Department of Pediatrics, The Indus Hospital, Karachi, Pakistan.

To describe the experience of thrombolysis using tissue plasminogen activator (tPA) in critically ill children admitted to the pediatric intensive care unit (PICU), retrospective review of medical records of all children (1 month-16 years), who were admitted in PICU since January 2014 to December 2017 and received systemic tPA for thrombolysis was done. Data was collected on a structured proforma and included thrombus location, tPA dose and duration, outcome (resolution, survival) and complications (bleeding). Total 9 patients (7 males, 2 females) received systemic tPA therapy for thrombolysis with mean age of 74.64 ± 69.58 months. Two patients had thrombus in femoral artery, 3 in IVC and 4 had intra-cardiac thrombosis. Median number of doses was 2 with a range of 1-5 doses. Complete resolution of the clot was noted in all except one patient. A standard starting dose of 0.01 mg/kg/h was used in all patients. Only one patient developed melena after TPA therapy which self-resolved. Systemic tPA therapy was very safe in pediatric critically ill patients and was effective for thrombolysis and did not show any adverse effects in children with varying underlying diagnosis.
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http://dx.doi.org/10.1007/s12288-018-0952-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186248PMC
October 2018

Brown-Vialetto-Van Laere syndrome: a novel diagnosis to a common presentation.

BMJ Case Rep 2018 Jun 27;2018. Epub 2018 Jun 27.

Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Brown-Vialetto-Van Laere syndrome (BVVLS) or riboflavin transporter deficiency (OMIM 211530) is a rare treatable autosomal recessive neurodegenerative disorder. This condition is associated with progressive pontobulbar palsy. We describe the clinical course of a 16-month-old boy with BVVLS and a novel homozygous mutation from Pakistan. Our patient presented with stridor and respiratory insufficiency. Hearing loss which is the most common sign of this condition was absent, making it an unusual presentation of BVVLS. His examination revealed ptosis and tongue fasciculation. His riboflavin receptor mutational analysis showed the homozygous mutation in the gene. Per oral riboflavin was administered, and subsequently, he was able to be weaned off the ventilator. Now the child is improving and attaining developmental milestones.
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http://dx.doi.org/10.1136/bcr-2018-224958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040568PMC
June 2018

Hemimegalencephaly: Seizure Outcome in an Infant after Hemispherectomy.

J Pediatr Neurosci 2018 Jan-Mar;13(1):106-108

Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Isolated hemimegalencephaly (iHME) is a rare form of congenital malformation of cortical development characterized by enlargement of all or part of one cerebral hemisphere. It typically presents with intractable seizures, developmental delay, contralateral hemiparesis, and hemianopia. We report a case of an 18-month-old girl who presented first with focal seizures at tenth day of life, with no other physical or behavioral abnormality. Initial EEG showed excessive sharp EEG transients more over the right hemisphere; repeated EEG showed spikes, polyspikes, sharps, and slow wave discharges predominately over the right hemisphere. MRI of the brain showed asymmetric enlargement of the right cerebral hemisphere, suggestive of hemimegalencephaly. Initial treatment with antiepileptic drugs (AEDs) was successful in controlling her seizures, but later on the seizures became intractable even on polytherapy of AEDs; finally, functional hemispherectomy was performed and she became seizure free. Identification of this and similar cases of iHME can help us to better understand this disorder and eventually to provide better treatment options for it.
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http://dx.doi.org/10.4103/JPN.JPN_56_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5982477PMC
June 2018

Training Pediatric Mechanical Ventilation to Front Line Pediatric Physicians.

J Coll Physicians Surg Pak 2018 Jun;28(6):492

Department of Pediatrics, The Indus Hospital, Karachi.

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http://dx.doi.org/10.29271/jcpsp.2018.06.492DOI Listing
June 2018

Frequency and Outcome of Acute Neurologic Complications after Congenital Heart Disease Surgery.

J Pediatr Neurosci 2017 Oct-Dec;12(4):328-331

Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Objectives: To determine the frequency and immediate outcome of acute neurologic complications (ANCs) in children undergoing congenital heart surgery (CHS).

Materials And Methods: In this retrospective study, all patients undergoing CHS at our hospital from January 2007 to June 2016 were included. Patients were followed up for the development of seizures, altered level of consciousness (ALOC), abnormal movements, and stroke. Results are presented as mean with standard deviation and frequency with percentages.

Results: Of 2000 patients who underwent CHS at our center during the study, 35 patients (1.75%) developed ANC. Seizures occurred in 28 (80%), ALOC in 5 (14%), clinical stroke in 2, brain death in 6 patients. Antiepileptic drugs (AEDs) were started in 32 patients, of which 13 patients required more than one AED. Mean length of stay was 10 ± 7.36 days. Of 35 patients who developed ANC, 7 expired during the study.

Conclusion: Neurological complications are scarce but significant morbidity after CHS at our center.
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http://dx.doi.org/10.4103/jpn.JPN_87_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5890551PMC
April 2018

Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit.

Pak J Med Sci 2018 Jan-Feb;34(1):106-109

Dr. Khadija Nuzhat Humayun, FCPS. Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Objectives: To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA.

Methods: Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied.

Results: Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay.

Conclusion: Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.
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http://dx.doi.org/10.12669/pjms.341.13875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856992PMC
April 2018

Relationship of Serum Procalcitonin, C-reactive Protein, and Lactic Acid to Organ Failure and Outcome in Critically Ill Pediatric Population.

Indian J Crit Care Med 2018 Feb;22(2):91-95

Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.

Objective: To evaluate the clinical and prognostic utility of procalcitonin (PCT), C-reactive protein (CRP), and lactic acid in children admitted to the Pediatric Intensive Care Unit (PICU) of a university teaching hospital.

Materials And Methods: Medical records of children (1 month-16 years) tested for serum PCT at the time of admission in the PICU of our hospital from July 1, 2013, to January 15, 2015, were reviewed. Within 24 h of admission, the Pediatric Risk of Mortality Score, blood cultures, white blood cell count, neutrophil counts, serum CRP, plasma lactic acid, and PCT were noted. Patient outcome was assessed at hospital discharge, and the patients were divided into nonsurvivors and survivors.

Results: A total of 167 children being admitted to the PICU were enrolled. The median age of the study population was 3 years (0-16 years), with 58.6% being males. Nonsurvivors had significantly higher lactic acid (4.7 mmol/L [2.07-7.6]; < 0.05) than that of the survivors (2 mmol/L [1.3-3]; < 0.05). In addition, nonsurvivors (94.4%; < 0.05) had greater incidence of multiple organ dysfunction syndrome (MODS) than that of the survivors (38.05%; < 0.05). Binary logistic regression showed age, MODS, and lactic acid to be associated with mortality.

Conclusions: This study found that in comparison to PCT and CRP, high plasma lactic acid levels are associated with the development of all-cause MODS and worse outcome in critically ill children admitted in PICU. Prediction of prognosis based on the lactic acid alone may contribute to improve patient management, but further studies are required to endorse our findings.
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http://dx.doi.org/10.4103/ijccm.IJCCM_4_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842463PMC
February 2018

Outcome Of Traumatic Brain Injury In Children By Using Rotterdam Score On Computed Tomography.

J Ayub Med Coll Abbottabad 2018 Jan-Mar;30(1):140-142

Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

Background: The Rotterdam Score (RS) on CT head is a new evolving clinical tool as a predictor of mortality in Traumatic Brain Injury (TBI). The objective of this study is to assess the outcome of children with TBI admitted in paediatric intensive care unit (PICU) of a tertiary-care, university hospital by using RS.

Methods: This was a prospective observational study conducted on children (age: 1mo -16yr) with TBI admitted in PICU of Aga Khan University Hospital from 2013 to 2016. RS on CT was calculated by a radiologist. All patients were managed according to according to Paediatric Brain Trauma Foundation Guidelines 2012.Demographic data, clinical variables and outcomes were recorded. Logistic regression analysis was applied to assess the association between outcome and R..

Results: Ninety-two cases were enrolled during four years. The median age was 77 months (3 months to 16 years) and 73 (79%) were male. The main cause of injury was RTA (60.9%) followed by fall (39.1%). Sixty-two patients (67%) had a post-resuscitation GCS of 8 or less. 54% (51) patients were managed conservatively. The RS of 1, 2, 3, 4 and 5 were present in 19, 36,19,15 and 3 patients. The mean RS was 2.4. The higher mortality rate was observed in high RS. The RS was significantly associated with mortality (OR 1.75, 95% CI 1.03-2.95; p<0.04).

Conclusions: Rotterdam Score on CT head can be used to predict mortality in paediatric patients with TBI.
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August 2018

Impact of pharmacist-led antibiotic stewardship program in a PICU of low/middle-income country.

BMJ Open Qual 2018 6;7(1):e000180. Epub 2018 Jan 6.

Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.

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http://dx.doi.org/10.1136/bmjoq-2017-000180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759741PMC
January 2018

Transfusion-Related Acute Lung Injury In A Paediatric Intensive Care Unit Of Pakistan.

J Ayub Med Coll Abbottabad 2017 Oct-Dec;29(4):702-705

Department of Paediatrics & Child Health, Aga Khan University Hospital Karachi, Pakistan.

Background: Transfusion-Related Acute Lung Injury (TRALI) is a major cause of transfusionrelated morbidity and mortality in the intensive care unit setting. There is a paucity of such data from Pakistan. The purpose of this study is to assess the incidence and outcome of TRALI in critically ill children admitted in a pediatric intensive care unit (PICU) of Pakistan.

Methods: This is a retrospective cohort study of all critically ill or injured children who developed TRALI or "possible" TRALI after blood transfusion based on Canadian Conference Consensus criteria in a closed multidisciplinary-cardiothoracic PICU from January 2012 to June 2016. The demographic, pertinent clinical data, transfusion-related variables and outcome of all cases of TRALI were recorded.

Results: Of total 2975 admissions in the PICU during study period, 35.8% (1066) received 5124 blood components. Eleven cases developed TRALI in our cohort. The incidence of TRALI was 1.03% per patient transfused and 0.19% (19/100,000 per blood product transfused). Median age was 8 (range 1-14) yr., 70 % (n=8) were male. Mean PRISM-III score was 16.3±6.7. Mean time interval for onset of TRALI was 2.73±1.67 hr. The postoperative cardiac surgical and hematology-oncology patients were most common categories (63.6%). Plasma and platelets were the most commomly identified trigger of TRALI. The case-specific mortality was 63.6% and the overall mortality was 10.7% (p<0.0001).

Conclusions: The incidence of TRALI in critically ill children is low, but is associated with high mortality. Critically ill children with high PRISM-III score, postoperative cardiac surgical and hematology-oncology patients are often affected by TRALI.
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June 2018

Non-Vascularized Autogenous Bone Grafts for Reconstruction of Maxillofacial Osseous Defects.

J Coll Physicians Surg Pak 2018 Jan;28(1):17-21

Department of Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi.

Objective: To determine the outcomes of non-vascularized bone grafts for reconstruction of maxillofacial defects.

Study Design: Case series.

Place And Duration Of Study: Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi, from January 2013 to December 2015.

Methodology: Descriptive analyses of 30 patients, who underwent maxillofacial reconstruction with non-vascularized bone grafts, were conducted. The demographic information, diagnosis, and type of graft harvested to reconstruct the defect were statistically analyzed. Outcomes of reconstruction with non-vascularized bone grafts were analyzed in terms of mouth opening, success of dental rehabilitation, and postoperative complications, i.e. surgical site infection and hardware loosening.

Results: A total of 30 patients ranging from 8 to 60 years (33.57 ±14.74 years) had maxillofacial defects reconstructed mostly due to gunshot injuries, followed by post-resection defects. Overall 15 cases (50%) were reconstructed with iliac crest cortico-cancellous bone graft, 11 cases (36.7%) with rib; while in four cases (13.3%), costochondral graft was used for reconstruction. In 26 cases (86.7%), graft was found to be successful. In three cases, re-operation for onlay bone graft was required to provide optimal dental rehabilitation; while in just one case, postoperative surgical site infection was observed.

Conclusion: Non-vascularized bone grafts provide a reasonable and effective modality for reconstruction of maxillofacial defects.
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http://dx.doi.org/10.29271/jcpsp.2018.01.17DOI Listing
January 2018

Teaching Basic Pediatric Intensive Care Course to Pediatric Residents and Consultants.

J Coll Physicians Surg Pak 2017 Oct;27(10):669

Department of Pediatrics, Aga Khan University Hospital, Karachi.

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http://dx.doi.org/2736DOI Listing
October 2017

Acute Necrotizing Encephalopathy of Childhood Secondary to Dengue Infection: A Case Report from Pakistan.

J Pediatr Neurosci 2017 Apr-Jun;12(2):165-167

Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.

Acute necrotizing encephalopathy of childhood (ANEC) is a rare condition mainly affecting children with a distinct clinico-radiologic pattern. Initially thought to be secondary to respiratory viral infections, there have been more insights to the pathogenesis of ANEC including genetics. We present a case of a girl who developed this condition with classical clinico-radiologic findings of ANEC secondary to severe dengue infection and could not survive. We report this case with the aim to raise awareness about this fatal complication of dengue infection as dengue has become a global health-care problem.
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http://dx.doi.org/10.4103/jpn.JPN_186_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588644PMC
September 2017

Hyperlactetemia And Its Trends In Critically Ill Children Admitted In Pediatric Intensive Care Unit Of A Developing Country.

J Ayub Med Coll Abbottabad 2016 Oct-Dec;28(4):660-663

Department Of Paediatrics and Child Health, Aga Khan University Karachi, Pakistan.

Background: There is increasing evidence that in setting of critical ailments clinical signs lag biomarkers like Lactate and hyperlactetemia can be the only marker for this disorder. This study was conducted to describe the incidence of hyperlactatemia in critically ill children and its association with outcome.

Methods: Retrospective review of medical records of all children who had their lactic acid (LA) levels measured during their admission in PICU from January 2014 to December 2015 was done. Demographic and clinical variables were recorded along with PICU therapies, outcome (Survived or expired) and development of multi-organ dysfunction. Results are presented as frequency with percentages and mean with standard deviation. Appropriate statistical tests were applied and p-value of <0.05 was taken as significant.

Results: Total 300 patients had their LA measured and 202 were included in the study. Males were 130 (64%) and mean age was 5.7±4.6 years. Hyperlactatemia was found in 68 (33%) patients and another 75 (37%) had a second LA level >4 mmol/L. Increasing LA trend was found in 79 (39%) patients. Diagnostic categories included cardiovascular diseases (45, 22%), central nervous system diseases (40, 20%), respiratory diseases (31, 15%), sepsis (28, 14%), and gastrointestinal diseases14 (7%). 168 (83%) needed mechanical ventilation. Mean pH was 7.31±0.15 and metabolic acidosis was observed in 91 patients (45%). Mean LA levels in survivors and non survivors were 3.3±3.12 and 5.35±5.47 respectively. Hyperlactatemia was associated with death (p=0.01) and development of MODS (p=0.03) on univariate analysis. On multivariate logistic regression rising lactate and development of MODS were significantly associated with death (p=<0.05, odds ratio (OR) 9.24 (95% confidence interval 1.55-55.20).

Conclusions: Hyperlactatemia and increasing LA trend in critically ill children are associated with worse outcome in PICU.
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November 2017

Paediatric External Ventricular Drains: Experience from a tertiary care hospital of a Developing Country.

J Pak Med Assoc 2016 10;66(Suppl 3)(10):S72-S74

Department of Surgery , Aga Khan University, Karachi.

The aim of the study was to describe indications and complications of external ventricular drain (EVD) placement in children aged between 1 month and 16 years. This retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, and comprised all children who underwent EVD placement from January 2007 to December 2014. Of the 177 patients identified, 117(66%) were males 60(34%) were girls. The overall mean age was 5.4±5.2 years. The median Glasgow Coma Scale score on presentation and discharge was 13 (interquartile range [IQR]: 7) and 15 (IQR: 4), respectively. Major diagnosis included intracranial tumour 60(34%), bacterial meningitis 34(19%), tuberculous meningitis 33(18.6%), and haemorrhage 23(13%). Clinical indications for EVD insertion were acute hydrocephalus secondary to infection 64(36.2%), tumour 54(30.5%), and haemorrhage 23(13%) ventriculoperitoneal shunt malfunction or infection 25(14.1%) and traumatic brain injury 11(6.2%). Complications were observed in 47(26%) patients including infections 25(14.1%), malfunction 11(6.2%), haemorrhage 6(3.4%), misplacement 3(1.7%) and obstruction 2(1.1%). Staphylococcus was the main organism isolated. Moreover, 25(14%) patients expired. Acute hydrocephalus was the major indication and EVD infection was the major complication.
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October 2016

Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country.

Indian J Crit Care Med 2016 May;20(5):291-4

Department of Pediatric and Child Health, Aga Khan University, Karachi, Sindh, Pakistan.

Background: Pediatric Intensive Care Unit (PICU) patients are often prescribed antibiotics with a low threshold in comparison to patients elsewhere. Irrational antibiotics use can lead to rapid emergence of drug resistance, so surveillance of their use is important.

Objectives: To evaluate the use of antibiotics in relation to bacteriological findings in PICU of a Tertiary Hospital.

Methods: Retrospective review of medical records of all children (age 1 month-16 years) admitted in our closed multidisciplinary-cardiothoracic PICU from January to June 2013 was performed, after approval from Ethical Review Committee. For each antibiotic, indication (prophylactic, empiric, therapeutic) and duration of use were recorded. All diagnoses of infections were recorded according to diagnostic criteria of IPSCC 2005. Results are presented as frequency and percentages and median with inter quartile range using SPSS version 19.

Results: All of the total 240 patients admitted in PICU during the study period received antibiotics: 43% (n = 104) prophylactically, 42% (n = 102) empirically, and 15% (n = 15) therapeutically. Median number of antibiotic use per patient in PICU was 3, with range of 1-7. 25% received 1 antibiotic, 23% received 2 antibiotics, 29% received 3 antibiotics, and rest received ≥4 antibiotics. Most commonly used antibiotics were cefazolin, meropenem, vancomycin and ceftriaxone, and most frequently used combination was meropenem and vancomycin. In majority of the cases, (70%) empiric antibiotic combinations were stopped in 72 h.

Conclusion: This is the first report of antibiotics use in PICU from our country, which shows that antibiotics are prescribed universally in our PICU. Strategies to assess the need for antibiotic use are needed.
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http://dx.doi.org/10.4103/0972-5229.182197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876651PMC
May 2016

Spectrum of Intracerebral Hemorrhage in Children: A Report from PICU of a Resource Limited Country.

Crit Care Res Pract 2016 3;2016:9124245. Epub 2016 Jan 3.

Department of Surgery, Section of Neurosurgery, Aga Khan University, Karachi, Pakistan.

Intracerebral hemorrhage (ICH) in children is a rare but disabling disease that accounts for almost half cases of stroke. We report our experience of ICH in children. Retrospective review of medical records of children (1 month-16 years) admitted in Pediatric Intensive Care Unit between January 2007 and December 2014 was done. Data collected included age, gender, presentation, examination findings, neuroimaging done (CT, MRI, and angiography) management (conservative/intervention), and outcome. Results are presented as frequency and percentages. Of the total 50 patients, 58% were male and 26% were <1 year. On presentation 44% had vomiting, 42% had seizures, and GCS < 8 while 40% had altered level of consciousness. Single bleed was present in 88%, 94% had supratentorial bleed, and 32% had intraventricular extension. 72% had bleed volume of <30 mL and 8% had >60 mL. CT scan was done in 98% patients and MRI in 34%, while 6% underwent conventional angiography. 60% patients were managed conservatively, 36% underwent neurosurgical intervention, and 6% underwent radiological vascular intervention. Hematologic causes were identified in 52% patients and vascular malformations in 14% and in 26% no cause could be identified. 26% of patients expired.
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http://dx.doi.org/10.1155/2016/9124245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735909PMC
February 2016
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