Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.

Background & Objectives: Heart diseases in paediatric population are considered to be significant contributors to mortality and morbidity. Congenital heart disease (CHD) as well as acquired heart disease (AHD) are frequent causes of hospital admission among children. This study was aimed at finding out frequency and pattern of heart diseases in admitted patients at The Children’s Hospital, Multan. Methods: This study is a retrospective chart review of five years at Paediatric Cardiology Department of The Children’s Hospital and The Institute of Child Health, Multan, Pakistan, from January 2015 to December 2019. Children aged one month to 15 years, admitted as a diagnosed case of heart disease on the basis of echocardiography were included. Results: Out of a total of 4115 confirmed cases of heart disease admitted during the study period, 3250 (79.0%) were CHD while 865 (21.0%) were AHD. Overall, 2861 (69.5%) patients were aged less than one year. VSD followed by ASD were the commonest acyanotic heart lesion seen among 927 (28.5%) and 644 (19.8%) cases while TOF was the commonest cyanotic type heart lesion found in 396 (12.2%). Rheumatic heart disease (RHD) was the commonest type of AHD, seen in 330 (38.2%) cases followed by acute myocarditis found in 230 (26.6%) cases. Conclusion: Burden of heart diseases is rising in our region. VSD, ASD and TOF were the most common types of CHDs while RHD and acute myocarditis were the most frequent types of AHDs. doi: https://doi.org/10.12669/pjms.36.6.2312 How to cite this:Arshad MS , Anwar-ul-Haq HM, Adnan M, Zulqarnain A. Frequency and pattern of Paediatric Heart Diseases: Five years experience at The Children’s Hospital, Multan. Pak J Med Sci. 2020;36(6):---------. doi: https://doi.org/10.12669/pjms.36.6.2312 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background & Objective: Persistent pulmonary hypertension of the newborn (PPHN) is described as severe respiratory failure along with hypoxaemia. PPHN is known to be linked with high morbidity and mortality around the world. This study was planned to determine the postnatal causes and assess the severity of persistent pulmonary hypertension of newborn in babies presenting to the Children’s Hospital, Multan. Methods: This observational study was conducted at the Department of Paediatric Cardiology, The Children Hospital &Institute of Child Health, Multan, Pakistan from July to December 2019. A total of 122 confirmed cases of PPHN admitted having gestational age above 34 weeks were enrolled. Demographic data of the newborns was recorded along with maternal medical history, pregnancy status and postnatal causes of PPHN. Severity of PPHN was also recorded. Results: Out of a total of 122 cases of PPHN, 81 (66.3%) were male. Majority, 78 (64.0%) had gestational age above 37 weeks. Mode of delivery as cesarean section was noted in 70 (57.4%). Meconium aspiration syndrome 52 (42.6%), birth asphyxia 48 (39.3%), respiratory distress syndrome 23 (18.8%) and sepsis 33 (27.0%) were found to be the commonest causes of PPHN. Severe PPHN was found to be the most frequent, noted among 63 (51.6%) while Moderate PPHN was observed in 40 (32.8%) and Mild PPHN in 19 (15.6%). Morality was noted among 26 (21.3%) of cases. Conclusion: Meconium aspiration syndrome, birth asphyxia and respiratory distress syndrome were the commonest postnatal causes of PPHN. Severe PPHN was found to be the most frequent form of PPHN. doi: https://doi.org/10.12669/pjms.37.5.2218 How to cite this:Arshad MS, Adnan M, Anwar-ul-Haq HM, Zulqarnain A. Postnatal causes and severity of persistent pulmonary Hypertension of Newborn. Pak J Med Sci. 2021;37(5):---------. doi: https://doi.org/10.12669/pjms.37.5.2218 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To determine the incidence of acute bilirubin encephalopathy (ABE) and its risk factors in neonates presenting with hyperbilirubinemia in a tertiary care children hospital. Methods: This descriptive observational study was conducted from June 2018 to June 2019. A total of 300 infants who were admitted in neonatal ICU with diagnosis of hyperbilirubinemia in The Children’s Hospital & The Institute of Child Health, Multan, Pakistan were included in this period. Incidence of ABE was noted. ABE was divided into two categories on the basis of severity of symptoms; mild ABE and moderate to severe ABE. Total serum bilirubin (TSB) in all neonates was measured in all patients in hospital laboratory using colorimetric method. ABO incompatibility and Rh factor incompatibility was also noted for each neonate. Results: Out of 300 neonates who presented with hyperbilirubinemia, ABE was diagnosed in only 42 (14.0%) neonates (mild ABE in 17 (5.7%) and moderate in 25 (8.3%). Out of 42 neonates of ABE, total serum bilirubin levels were 20-29.9 mg/dL in 24 (40.5%) neonates, and >30 mg/dL in 18 (42.8%) neonates. Pre-term birth was a significant risk factor of ABE; 23.8% in ABE and 10.70% in non-ABE (p-value 0.01). During treatment, 02 (4.76%) neonates expired due to ABE. Conclusion: In present study, ABE was diagnosed in 14.0% neonates who presented with hyperbilirubinemia. We found pre-term delivery as a significant risk factor of ABE. doi: https://doi.org/10.12669/pjms.36.6.2222 How to cite this:Ahmad M, Rehman A, Adnan M, Surani MK. Acute bilirubin encephalopathy and its associated risk factors in a tertiary care hospital, Pakistan. Pak J Med Sci. 2020;36(6):---------. doi: https://doi.org/10.12669/pjms.36.6.2222 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To evaluate the cardiac status of newborns in terms of structural and functional heart diseases. Methodology: This descriptive study was conducted at Paediatric Cardiology Department of “The Children’s Hospital and The Institute of Child Health”, Multan, Pakistan, from January 2017 to December 2019. Neonates aged 0-28 days and referred for echocardiographic evaluation were enrolled. Diagnostic findings were confirmed with the assistance of echocardiography. We were focused on analyzing total number and types of heart diseases along with gender distribution during the study period. Results: During the study period, a total of 2729 newborns were evaluated. We noted 1523 (55.8%) newborns as structurally and functionally normal, 866 (31.7%) had congenital heart disease, 69 (2.5%) duct dependent lesions, 248 (9.1%) persistent pulmonary hypertension and 23 (0.8%) left ventricular (LV) dysfunction but with structurally normal heart. Newborns with LV dysfunction might have hypoxic myocardial damage, metabolic derangements or acute myocarditis. Ventricular Septal Defect (VSD) followed by Patent Ductus Arteriosus (PDA) and Atrial Septal Defect (ASD) were the most frequent types of acyanotic CHD observed in 248 (28.2%), 171 (19.7%) and 100 (11.5%) neonates respectively while Tetralogy of Fallot (TOF) was the most common type of cyanotic CHD 74 (8.5%). Conclusion: VSD followed by PDA, ASD and TOF were the most common types of CHD among neonates. Diagnosis of congenital heart defects in the early age is pointing towards improvement in healthcare facilities.