Cocaine Use is Associated with More Rapid Clot Formation and Weaker Clot Strength in Acute Stroke Patients

INTRODUCTION

1.1.Cocaine use is a known risk factor for stroke and has been associated with worse outcomes. Cocaine may cause an altered coagulable state by a number of different proposed mechanisms, including platelet activation, endothelial injury, and tissue factor expression. This study analyzes the effect of cocaine use on Thrombelastography (TEG) in acute stroke patients.

PATIENT AND METHODS

1.2.Patients presenting with Acute Ischemic Stroke (AIS) and spontaneous Intracerebral Hemorrhage (ICH) to a single academic center between 2009 and 2014 were prospectively enrolled. Blood was collected for TEG analysis at the time of presentation. Patient demographics and baseline TEG values were compared between two groups: cocaine and non-cocaine users. Multivariable Quantile regression models were used to compare the median TEG components between groups after controlling for the effect of confounders.

RESULTS

1.3.91 patients were included, 53 with AIS and 38 with ICH. 8 (8.8%) patients were positive for cocaine, 4 (50%) with AIS, and 4 (50%) with ICH. There were no significant differences in age, blood pressure, platelet count, or PT/PTT between the cocaine positive and cocaine negative group. Following multivariable analysis, and adjusting for factors known to influence TEG including stroke subtype, cocaine use was associated with shortened median R time (time to initiate clotting) of 3.8 minutes compared to 4.8 minutes in non-cocaine users (p=0.04). Delta (thrombin burst) was also earlier among cocaine users (0.4 minutes) compared with non-cocaine users (0.5 min, p=0.04). The median MA and G (measurements of final clot strength) were reduced in cocaine users (MA=62.5 mm, G=7.8 dynes/cm2) compared to non-cocaine users (MA=66.5 mm, G=10.1 dynes/cm2; p=0.047, p=0.04, respectively).

CONCLUSION

1.4.Cocaine users demonstrate more rapid clot formation but reduced overall clot strength based on admission TEG values.

The Effect of Ignoring Statistical Interactions in Regression Analyses Conducted in Epidemiologic Studies: An Example with Survival Analysis Using Cox Proportional Hazards Regression Model

OBJECTIVE

To demonstrate the adverse impact of ignoring statistical interactions in regression models used in epidemiologic studies.

STUDY DESIGN AND SETTING

Based on different scenarios that involved known values for coefficient of the interaction term in Cox regression models we generated 1000 samples of size 600 each. The simulated samples and a real life data set from the Cameron County Hispanic Cohort were used to evaluate the effect of ignoring statistical interactions in these models.

RESULTS

Compared to correctly specified Cox regression models with interaction terms, misspecified models without interaction terms resulted in up to 8.95 fold bias in estimated regression coefficients. Whereas when data were generated from a perfect additive Cox proportional hazards regression model the inclusion of the interaction between the two covariates resulted in only 2% estimated bias in main effect regression coefficients estimates, but did not alter the main findings of no significant interactions.

CONCLUSIONS

When the effects are synergic, the failure to account for an interaction effect could lead to bias and misinterpretation of the results, and in some instances to incorrect policy decisions. Best practices in regression analysis must include identification of interactions, including for analysis of data from epidemiologic studies.

Patient refusal of thrombolytic therapy for suspected acute ischemic stroke

OBJECTIVE

To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA.

METHODS

Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0-1), good (mRS: 0-2), and poor (mRS: 3-6).

RESULTS

Over 7·5 years, 30 (4·2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0·63, 95% CI 0·50-0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1·02, 95% CI 1·01-1·03), lower NIHSS (OR 1·11, 95% CI 1·03-1·18), a higher proportion of stroke mimics (OR 17·61, 95% CI 6·20-50·02) and shorter hospital stay (OR 1·32, 95% CI 1·09-1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1·37, 95% CI 1·06-1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1·61, 95% CI 0·69-3·73).

CONCLUSION

The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic.

Placental vascular pathology findings and pathways to preterm delivery

The authors examined the associations between placental vascular findings and preterm delivery in 1,053 subcohort women (239 preterm, 814 term) from a Michigan pregnancy cohort study (1998-2004). Twenty-nine placental vascular variables from microscopic examinations were grouped into 5 constructs: 3 maternal constructs-obstructive lesions (MV-O), bleeding/vessel integrity (MV-I), and lack of physiologic conversion of maternal spiral arteries (MV-D)--and 2 fetal constructs--obstructive lesions (FV-O) and bleeding/vessel integrity (FV-I). Construct-specific scores were created by adding the number of positive findings and deriving a dichotomous variable to approximate the top quintile ("high") and bottom 4 quintiles ("not high") within each construct. In multivariate polytomous logistic regression models, medically indicated preterm delivery at <35 weeks was significantly associated with high scores for each of the vascular constructs; adjusted odds ratios ranged from 2.4 to 5.4. Spontaneous preterm delivery at 35-36 weeks was significantly associated with a high score on any 1 of 3 constructs: MV-I, MV-D, and FV-I. Spontaneous preterm delivery at <35 weeks was significantly associated with a high score on 2 or more of 3 constructs: MV-I, MV-D, and FV-I; adjusted odds ratios ranged from 4.1 to 7.4. These results support a role for various placental vascular lesions in medically indicated and spontaneous preterm delivery.

The role of family configuration in early childhood intellectual development in the context of an extended family system in Pakistan

CONTEXT

The confluence theory of intelligence by Zajonc and Markus emphasizes that individual intellectual difference of children manifests itself in the context of family configuration. Instead of assuming its generalizability, careful scientific work is required before applying the model to South Asian cultures where, predominantly, an extended family type exists.

AIMS

To assess the role of extended family configuration on the child's intellectual development in a South Asian setting.

SETTINGS AND DESIGN

A cross-sectional study was conducted on 4-5-year-old preschool children residing in Karachi, Pakistan.

MATERIALS AND METHODS

Three hundred and forty-two child and mother dyads were assessed through a validated cognitive psychometric tool and through a structured questionnaire. Children who were registered at the main Mother and Child Health Centres (MCH) of the Aga Khan Health Services, Pakistan (AKHSP) Karachi and who were born between July 1st 1993-June 30th 1994 with traceable birth records at the maternity homes, were considered for this study.

STATISTICAL ANALYSIS

Multivariate linear regression models were used to identify the individual effect of family configuration on the intellectual scores.

RESULTS

Family configuration variables such as number of co-residents ( P P CONCLUSION: The findings suggest the positive role of co-residents of an extended family environment on the intellectual development in early childhood.

Multivariate analysis of risk factors associated with genital ulcer disease among incarcerated males in Sindh

OBJECTIVE

To evaluate the potential risk behaviors associated with the lifetime risk of self reported genital ulcer disease (GUD) among prison inmates.

SETTING

Prison inmates from 14 prisons of Sindh Province.

METHODS

A cross-sectional study was conducted on 3395 prison inmates during July to December 1994. A questionnaire was used to assess the lifetime risk of self-reported GUD (whether or not the subject was ever affected with GUD up to present age) and to investigate demographic markers and risk behaviors for their possible association with lifetime risk of GUD using logistic regression analysis.

RESULTS

The reported lifetime risk of GUD in the study sample was 11.4% (386/3395). In final multivariate logistic regression model the sexual behaviors which were independently associated with GUD were having sexual intercourse with female (adjusted OR = 1.7; 95% CI: 1.3-2.3, P=0.0002), sexual intercourse with a prostitute (adjusted OR = 1.5; 95% CI: 1.2-2.0, P=0.0008), sexual intercourse with man (adjusted OR = 2.2; 95% CI: 1.7-2.7, P=<0.001) and sexual intercourse with man during current incarceration (adjusted OR = 1.9; 95% CI: 1.2-2.9, P=0.0071).

CONCLUSION

Health education needs to re-enforce monogamous relationship for high risk groups such as in our study. Although infrequent condom use was not a risk factor for GUD in this study, yet based on the results of previous studies, promotion of condom use should be the component of health education program (JPMA 50:115;2000).

A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan

BACKGROUND

Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting.

AIM

The study was carried out to identify risk factors for NNT in Karachi.

MATERIALS AND METHODS

Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case.

STATISTICAL ANALYSIS

Conditional logistic regression was performed to assess the independent effect of factors associated with NNT.

RESULTS

The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%.

CONCLUSION

Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.

Sensitivity of 14-3-3 protein test varies in subtypes of sporadic Creutzfeldt-Jakob disease

BACKGROUND

The increase of the 14-3-3 protein in CSF is used as a diagnostic test in Creutzfeldt-Jakob disease (CJD), but the sensitivity and specificity of the 14-3-3 test are disputed. One reason for the dispute may be the recently established heterogeneity of sporadic CJD. The relationship between CSF 14-3-3 protein and sporadic CJD subtypes, distinguished by electrophoretic mobility of proteinase K-resistant prion protein (PrP(Sc)) and genotype at codon 129 of the prion protein gene, has not been elucidated.

METHODS

The authors examined the 14-3-3 protein test in 90 patients with sporadic CJD. PrP(Sc) type (type 1 or type 2) and the genotype at polymorphic codon 129 were determined in each patient. Mutations were excluded by prion gene sequencing.

RESULTS

The authors' findings indicate that the sensitivity of the 14-3-3 test is higher in patients with molecular features of the classic sporadic CJD than in patients with the nonclassic CJD subtypes. The difference appears to be related to the PrP(Sc) type and not to the codon 129 genotype. Disease duration before 14-3-3 testing might also have an influence because it was shorter in classic sporadic CJD.

CONCLUSION

The Creutzfeldt-Jakob disease clinical subtype should be considered when interpreting results of the 14-3-3 test.

Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan

A case control study was conducted to identify the association of therapeutic injections with acute hepatitis B virus (HBV) infection in Karachi, Pakistan. We enrolled 67 cases of acute HBV infection (IgM anti-HBc positive) and 247 controls (anti-HBc negative) from four hospitals of Karachi during July 2000-June 2001. Exposure to various risk factors during the period relevant to the incubation period of HBV was recorded both from cases and controls using a structured questionnaire. Multivariate logistic regression analysis of the data showed that cases were more likely to have received one injection (OR = 4.0; 95 % CI 1.4, 11.1), or more than one injection (OR = 6.3; 95 % CI 3.2, 12.4) compared to controls. The estimated population attributable risk (PAR) for therapeutic injections was 53%. Also the cases compared to controls were more likely to have household size of seven or more (OR = 1.9; 95 % CI 0.95, 3.9). This study showed that unsafe therapeutic injections appear to be the major risk factor for acute HBV infection and needs immediate focus from public health stand point.

Prevalence of and factors associated with anxiety and depression among women in a lower middle class semi-urban community of Karachi, Pakistan

OBJECTIVE

To study the prevalence of, and factors associated with anxiety and depression among women.

DESIGN

A cross sectional survey.

SETTING

A lower middle class semi-urban community of Karachi, Pakistan.

PARTICIPANTS

A total of 1218 women between the ages of 18-50 years.

METHODOLOGY

Systematically every third household was identified from which a woman was randomly selected. The Aga Khan University Anxiety and Depression Scale and a socio-demographic questionnaire were administered verbally by trained interviewers for assessing the prevalence of, and associated factors for anxiety and depression.

RESULTS

A prevalence of 30% was found. Increasing age, lack of education and verbal abuse were the associated factors found to have an independent relationship.

CONCLUSION

Providing education and reducing domestic abuse could lead to decrease in the prevalence of anxiety and depression in women.

Prevalence and risk factors associated with tuberculin skin test positivity among household contacts of smear-positive pulnionary tuberculosis cases in Umerkot, Pakistan

STUDY POPULATION AND SETTING

Household contacts of acid-fast bacilli (AFB) sputum smear-positive tuberculosis patients in the Umerkot Taluka, Sindh, Pakistan.

OBJECTIVE

To estimate the prevalence of and identify risk factors associated with tuberculin skin test (TST) positivity among household contacts of acid-fast bacilli (AFB) sputum smear-positive pulmonary tuberculosis cases.

DESIGN

A cross-sectional study of household contacts of AFB sputum smear-positive tuberculosis cases, registered at the Umerkot Anti-Tuberculosis Association clinic from August 1999 to September 1999. The contact's Mycobacterium tuberculosis infection status was assessed using TST. On the day of the TST, a pre-designed questionnaire was administered to collect data on putative risk factors for TST positivity among contacts. The data were analysed using a marginal logistic regression model by the method of generalised estimating equations (GEE) to determine risk factors independently associated with TST positivity.

RESULTS

The prevalence of TST positivity among household contacts of AFB sputum smear-positive index patients was 49.4%. The final multivariate GEE model showed that contact's age and sleeping site relative to the index case, the intensity of the index case's AFB sputum-smear positivity and the contact's BCG scar status were independent predictors of TST positivity among household contacts of AFB sputum smear-positive index cases.

CONCLUSIONS

The results suggest that the household contacts of AFB sputum smear-positive tuberculosis patients in a poor neighbourhood of rural Sindh had a high prevalence of M. tuberculosis infection as determined by TST. Poor housing conditions seem to contribute to the spread of M. tuberculosis infection. Early diagnosis of pulmonary TB through evaluation of TST-positive household contacts, followed by appropriate therapy, may prevent further spread of M. tuberculosis infection. We recommend an awareness programme to prevent household contacts from acquiring M. tuberculosis infection from smear-positive pulmonary TB cases.

Prevalence and risk factors for intrafamilial transmission of hepatitis C virus in Karachi, Pakistan

Household contacts of hepatitis C virus (HCV)-positive patients are considered at increased risk of HCV infection. This cross-sectional study during April through June 1999 assessed the prevalence and risk behaviours associated with HCV seropositivity among the household contacts of HCV seropositive thalassaemic children in Karachi, Pakistan. Among the 341 household contacts of 86 thalassaemic HCV seropositive children who were tested, 70 (20.5%) were positive for anti-HCV antibodies. The stratified analysis showed that HCV seroprevalence among the contacts did not differ significantly by the gender of the index patient and the type of relationship of contact with the index patient. However, HCV seroprevalences among the fathers and mothers of male index patients was substantially higher compared to those of female index patients. HCV RNA was recovered and genotyped from nine index patients and corresponding nine HCV-seropositive household contacts. HCV genotype 3a and 3b were found in 89% (8/9) and 11% (1/9) of the pairs, respectively. The final multivariable conditional logistic regression model revealed that after adjusting for the effect of ethnicity and past hospital admission history, the HCV-seropositive household contacts were more likely than HCV seronegative household contacts to have been bitten by the carrier [adjusted matched odds ratio (mOR)=2.6, 95% CI 1.3-5.2] or have shared a toothbrush with the carrier (adjusted mOR=8.2; 95% CI 1.56-43.5). Control efforts should focus on the risk behaviours.

Epidermal growth factor receptor (EGFR) as a prognostic marker: an immunohistochemical study on 315 consecutive breast carcinoma patients

OBJECTIVE

To assess the independent and interdependent prognostic value of epidermal growth factor receptor (EGFR) in carcinoma of breast in female population. The Type 1 family of growth factor receptors includes epidermal growth factor receptor (EGFR also known as EGFR1).

METHODS

The expression of EGFR protein was analysed immunohistochemically on 315 tumour specimens of infiltrating ductal carcinoma of breast. These patients also had axillary lymph nodes sampling.

RESULTS

Overexpression and/or amplification of EGFR was observed in 70 (22.00%) tumours. Eleven (16%) were grade I, 43 (61%) grade II and 16 (23%) grade III tumours. Axillary lymph node metastasis had significant correlation with intensified positivity of EGFR (p < 0.05). Significant number of EGFR positive patients developed local recurrence and distant metastases to brain, liver and bone (p < 0.05). EGFR positivity showed significant correlation with the disease free and overall survival (p < 0.05). At a median follow-up of 48 (4 years) months in EGFR positive patients, the overall survival was 3.39 years and disease free survival was 2.86 years. EGFR negative tumour patients showed a better survival. In this group the overall survival was 4.62 years and the disease free survival was 4 years.

CONCLUSION

EGFR analysis can be a useful indicator for the selection of patients who are at the high risk, for hormonal therapy decisions and can be useful as a target for new treatment modalities.

Relationship of p53 expression with clinicopathological variables and disease outcome: a prospective study on 315 consecutive breast carcinoma patients

Breast cancer is an increasingly important cause of illness and death among women. In recent years several novel prognostic determinants of breast cancer have been identified which includes p53. Alterations of p53 are one of the most common abnormalities detected in primary breast cancer. In this study alteration of p53 in primary carcinoma breast was correlated with other pathological variables and disease outcome. In this prospective study the expression of p53 oncoprotein was analyzed immunohistochemically on 315 patient's tumour specimens of infiltrating ductal carcinoma of breast from 1992 to 1997. These patients also had axillary lymph nodes sampling. Both univariate and multivariate statistical analysis was performed to analyze results including disease outcome. Overexpression of p53 was observed in 55.23% tumours. Axillary lymph node metastasis had significant correlation with positivity of p53 (p<0.05). A significant number of p53 patients developed local recurrence and distant metastases to brain, liver, lung and bone (p< 0.05). At a median follow-up of 48 months (4 years) in p53 positive patients, the median overall survival (OS) was 3.0 years and disease free survival (DFS) was 2.5 years. p53 negative tumour patients showed a better survival. In this group the median OS was 3.8 years and the DFS was 3.3 years. The above findings have reinforced the view that p53 immunohistochemical detection is of help in detecting a subgroup of breast carcinoma patients who are at high risk. This may also be of particular relevance in decisions regarding adjuvant chemotherapy to these patients.

Case control study of prognostic markers and disease outcome in inflammatory carcinoma breast: a unique clinical experience

Inflammatory breast carcinoma (IBC) is a rare but aggressive form of breast cancer. In this first-ever study, we investigated the role of nine prognostic markers' expression (estrogen receptor [ER], progesterone receptor [PR], p53, C-erbB-2, epidermal growth factor receptor [EGFR], cathepsin D [CD], proliferating cell nuclear antigen [PCNA], DNA ploidy, and S-phase fraction [SPF]) and disease outcome in IBC cases compared with the control group. A case control study of IBC was conducted on 40 test cases with two controls per case matching age, grade, and number of axillary lymph nodes sampled. During 7 years of this study, 10% of all patients with breast cancer had IBC. In this study, 84% of IBC cases showed positive axillary lymph nodes compared with 63% in control group. The expression of nine prognostic markers, that is, ER, PR, p53, C-erbB-2, EGFR, CD, PCNA, SPF, and DNA ploidy, was studied by immunohistochemistry and flow cytometry. Hormone receptor status showed an inverse correlation (p < 0.05). Among p53, C-erbB-2, EGFR, and CD in the IBC group, only p53 showed a significant correlation, with 70% positivity in IBC versus 48% positivity in the control group (p < 0.05). Much higher SPF and PCNA positivity was seen in the IBC group compared with the control group (p < 0.05). DNA ploidy also showed a significant correlation compared with the control group (p < 0.05). After a median follow up of 18 months, median overall survival in the IBC group was 1.8 years (range 0.6-5.8 years) compared with 3.0 years (range 2.5-7.0 years), with a p value of 0.0001.

Microbiologic effectiveness of hand washing with soap in an urban squatter settlement, Karachi, Pakistan

We conducted a study in a squatter settlement in Karachi, Pakistan where residents report commonly washing their hands to determine if providing soap, encouraging hand washing, and improving wash-water quality would improve hand cleanliness. We allocated interventions to 75 mothers and collected hand-rinse samples on unannounced visits. In the final model compared with mothers who received no hand-washing intervention, mothers who received soap would be expected to have 65% fewer thermotolerant coliform bacteria on their hands (95% CI 40%, 79%) and mothers who received soap, a safe water storage vessel, hypochlorite for water treatment, and instructions to wash their hands with soap and chlorinated water would be expected to have 74% fewer (95% CI 57%, 84%). The difference between those who received soap alone, and those who received soap plus the safe water vessel was not significant (P = 0.26). Providing soap and promoting hand washing measurably improved mothers' hand cleanliness even when used with contaminated water.

Risk factors for hepatitis C virus infection in male adults in Rawalpindi-Islamabad, Pakistan

OBJECTIVE

To identify risk factors associated with HCV infection in Islamabad-Rawalpindi.

METHODS

Fifty-seven cases and 180 controls were enrolled from various departments of the nine major hospitals of the Rawalpindi-Islamabad during July-September 1998. Cases were enzyme-linked immunosorbent assay (ELISA) positive for antibodies to HCV (anti-HCV), aged 20-70 years, and residents of Islamabad or Rawalpindi division. Controls were anti-HCV ELISA negatives of the same age range and from the same area. A structured questionnaire was used to collect data on demographic variables and potential risk factors, which was analysed by logistic regression to calculate crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for risk factors.

RESULTS

The final multivariate logistic regression model revealed that after adjusting for age, cases were more likely to have received therapeutic injections in the past 10 years (1-10 vs. 0 therapeutic injections; adjusted OR=2.8, 95% CI: 1.1-7.1; > 10 vs. 0 therapeutic injections; adjusted OR=3.1, 95% CI: 1.2-7.9) and were significantly more likely to have daily face (adjusted OR=5.1, 95% CI: 1.5-17.0) and armpit shaves (adjusted OR=2.9, 95% CI: 1.3-6.5) by a barber.

CONCLUSION

HCV control and prevention programs in this region should include safe injection practices and educate men about the risk of HCV infection from contaminated instruments used by barbers.

HIV/AIDS knowledge, attitudes and beliefs based prediction models for practices in prison inmates, Sindh, Pakistan

This study was conducted on prison inmates in Sindh to determine whether HIV/AIDS related knowledge, attitudes and beliefs can predict their practices which risk HIV infection. A pre-designed questionnaire was administered in this cross-sectional study to collect the data on HIV/AIDS related knowledge, attitudes, beliefs, practices and demographic variables in a systematic sample of 3,395 prison inmates during July 1994. The data on responses of inmates to HIV/AIDS related knowledge, attitudes, and beliefs were analyzed and a clear interpretable factor structure emerged for each set of questions labeled as knowledge, attitude and beliefs. Similarly based on responses of inmates to practice questions, three factors emerged and were labeled as heterosexuality, homosexuality and drugs. The standardized factor scores of inmates for each of these six factors were computed and used in further analyses. Multiple linear regression analyses were carried out separately using heterosexuality, homosexuality and drugs factors score as dependent variables to identify if any of the independent variables (demographic variables, knowledge beliefs and attitude) predict these practice factors. The model for heterosexuality explained 23% of the variance and included HIV/AIDS related knowledge, beliefs, age, ethnicity and marital status and duration of imprisonment (F = 84.33, p < 0.001; R2= 23.0). The predictors in the model for homosexuality together explained 10% of the variance and included significant contribution by belief, martial status, ethnicity, education, age and duration of imprisonment (F = 24.76, p < 0.001; R2= 0.10). The model for drugs had significant contributions from HIV/AIDS related beliefs, marital status and ethnicity (F = 20.10, p < 0.001; R2= 0.03). Implications of prevention program based on these results are considered.

Predictability of medical students' performance at the Aga Khan University from admission test scores, interview ratings and systems of education

INTRODUCTION

Performance in an admission test and carefully conducted, structured interview provides a uniform basis for the assessment of applicants prepared in different systems of education for admission to an institute of higher professional learning. We studied the predictability of the system of education followed by the students prior to entrance into the Medical College, the admission test scores, and interview ratings on performance after five trimesters at the Aga Khan University Medical College.

METHOD

A cohort of 374 medical students who were admitted during 1989--1994, were considered. The associations between the admission test score, interview ratings, system of education, and the scores obtained for anatomy, physiology, biochemistry and community health sciences examinations held after five trimesters were analysed using appropriate statistical procedures.

RESULTS

Interview ratings were associated with the scores in Physiology but not other subjects. The chief finding of this study was the association between the system of education and performance in both the admission test and the examination after five trimesters. Students who followed the British school curricula for 13 years scored significantly higher than those who followed the 12 years of the Pakistani system. When controlled for the admission test score, the difference in mean scores of the two groups was still evident for two subjects; community health sciences and physiology.

CONCLUSION

We believe that the evidence indicates differences in learning methods inculcated by the system of education prior to entry into the Medical College, notwithstanding the 1-year difference in duration of education.

Significance of immunohistochemical c-ErbB-2 product localisation pattern for prognosis in human breast cancer

Breast cancer is an increasingly important cause of illness and death among women. In recent years several novel prognostic determinants of breast cancer have been identified, including c-ErbB-2. In this study, expression of c-ErbB-2 in breast carcinoma was correlated with axillary lymph node metastases and disease outcome. The expression of c-ErbB-2 oncoprotein was analysed in 315 tumor specimens of infiltrating ductal carcinoma of breast. They were categorized according to the modified Bloom and Richardson criteria into three histological grades. These patients also had axillary lymph nodes sampling. The expression of c-ErbB-2 oncoprotein was analysed immunohistochemically. Over expression of c-ErbB-2 were observed in 39.36% tumors. Axillary lymph node metastasis had significant correlation with intensified positivity of c-ErbB-2. C-ErbB-2 positive patients did show resistance to chemotherapy when compared for recurrence and distant metastases following surgery (p< 0.05). At a median follow-up of 48 months in c-ErbB-2 positive patients, the overall survival was 3.0 years and disease free survival was 2.5 years. c-ErbB-2 negative tumor patients showed a far better survival. In this group the overall survival was 4.44 years and the disease free survival was 3.78 years. These findings reinforce the view that c-ErbB-2 immunohistochemical detection is of help in detecting a subgroup of breast carcinoma patients who are at high risk. This may also be of particular relevance in decisions regarding adjuvant chemotherapy to these patients.

Prevalence of plasmodium slide positivity among the children treated for malaria, Jhangara, Sindh

OBJECTIVE

The aim of the study was to estimate the prevalence of malaria amongst the children with fever or history of fever.

SETTING

Rural Health Centre (RHC), Jhangara, a town near the Manchhar Lake in Taluka Sehwan, District Dadu, Sindh.

SUBJECTS

Four hundred and thirty eight children of 6 months to 10 years of age, who attended above described RHC during August through October 1997.

METHODS

A Sindhi-translated standard questionnaire was used to record symptoms and duration of child's illness. Each child was physically examined, had their axillary temperature measured; and blood samples were collected from which Giemsa stained thick and thin blood films were examined for presence of Plasmodium parasites.

RESULTS

The median age of the studied children was 24 months and 57% (250/438) were boys. Fifty three percent (231) of the study subjects were from Jhangara Town, 40% (177) and 7% (30) came from other villages and villages near to the Manchhar Lake respectively. The prevalence of Plasmodium slide positivity was 5.9% (26/438). Among Plasmodium slide positive children, 65% (17/26) were positive for P. falciparum and 35% (9/26) for P. vivax. Among the P. falciparum positive children, 88% (15/26) had scanty (MP, 1-10/100 fields) and 12% (2/26) had moderate density (MP, 10-100/100 fields) of infection. Seventeen percent (6/30) of the children from villages close to Manchhar Lake were Plasmodium slide positive compared to 7% (17/53) and 3% (5/177) from Jhangara town and other villages respectively. Cough, diarrhea, abdominal distention and vomiting were the commonly reported symptoms among the children of all ages at the time of interview. Guardians reported fever as part of the illness in all children, although during physical examination only 128 (29%) had axillary temperature > or = 37.5 degrees C. Pallor as an indicator for anemia, rash and prickly heat were the major recorded observations.

CONCLUSION

The Prevalence of Plasmodium positivity was higher in children who attended from villages close to Manchhar lake, therefore especial measure needs to be considered for this area. In addition, the health care workers in rural Sindh need to adopt appropriate guidelines to differentiate the clinical malarial patients from patients with other potential infectious diseases, which may need other treatment.

Risk factors for stunting and wasting at age six, twelve and twenty-four months for squatter children of Karachi, Pakistan

OBJECTIVE

A high proportion of stunting and wasting in children under-five has been reported from developing countries. This paper presents the nutritional status of a two year cohort of urban squatter children in Karachi, Pakistan and assesses risk factors for wasting and stunting at the reference ages of six, twelve and twenty-four months.

METHODS

A birth cohort of 738 children were visited at specific intervals by trained nurses to collect information on anthropometric measurements, feeding practices and intercurrent illnesses. Socioeconomic and demographic information included water and sanitation facilities, availability of electricity, type of house construction material and average monthly income. Information about the mother's reproductive history was also obtained.

RESULTS

At two years the proportion of stunting and wasting was 41.8% and 10.6% respectively. Intrauterine growth retarded children had a higher risk of stunting and wasting at all reference ages as compared to children who were appropriate for gestational age. In the logistic regression models, intrauterine growth retardation was the only significant risk factor that remained in all models at each reference age.

CONCLUSION

The consistent association of IUGR for stunting and wasting adds to the growing body of evidence that by improving maternal health we will ultimately break the vicious cycle of malnourishment and improve the health and well-being of future generations. We suggest interventions to improve the nutritional status of Pakistani urban children living in squatter settlements focused on mothers and children.

Multivariate analysis of risk factors associated with genital ulcer disease among incarcerated males in Sindh

OBJECTIVE

To evaluate the potential risk behaviors associated with the lifetime risk of self reported genital ulcer disease (GUD) among prison inmates.

SETTING

Prison inmates from 14 prisons of Sindh Province.

METHODS

A cross-sectional study was conducted on 3395 prison inmates during July to December, 1994. A questionnaire was used to assess the lifetime risk of self-reported GUD (whether or not the subject was ever affected with GUD up to present age) and to investigate demographic markers and risk behaviors for their possible association with lifetime risk of GUD using logistic regression analysis.

RESULTS

The reported lifetime risk of GUD in the study sample was 11.4% (386/3395). In final multivariate logistic regression model the sexual behaviors which were independently associated with GUD were having sexual intercourse with female (adjusted OR = 1.7; 95% CI: 1.3-2.3, P = 0.0002), sexual intercourse with a prostitute (adjusted OR = 1.5; 95% CI: 1.2-2.0, P = 0.0008), sexual intercourse with man (adjusted OR = 2.2; 95% CI: 1.7-2.7, P = < 0.001) and sexual intercourse with man during current incarceration (adjusted OR = 1.9; 95% CI: 1.2-2.9, P = 0.0071).

CONCLUSION

Health education needs to re-enforce monogamous relationship for high risk groups such as in our study. Although infrequent condom use was not a risk factor for GUD in this study, yet based on the results of previous studies, promotion of condom use should be the component of health education program.

The effect of grandmultiparity on pregnancy related complications: the Aga Khan University experience

BACKGROUND

Grandmultiparity has been associated with complications for both mother and the fetus.

OBJECTIVE

To evaluate if grandmultiparity is a risk factor in the presence of adequate antenatal care.

SETTING

A tertiary care teaching hospital.

METHODS

It was a retrospective study conducted in the department of Obstetrics & Gynecology at The Aga Khan University Hospital in Karachi. During this period 9253 women were delivered, out of these 143 booked grandmultiparas (GMP) served as cases. The outcome of these women was compared with 430 non-grandmultiparas (NGMP). Logistic regression model was used to adjust for potential confounders.

RESULTS

Grandmultiparas had almost three times increased risk of having postpartum hemorrhage compared to NGMP group. Similarly, there were significantly low five-minute apgars in the GMPs compared to the NGMP group. Although the neonatal intensive care admissions were three times more in the GMPs but this did not reach statistical significance due to small number of cases in both groups.

CONCLUSION

Our study indicates that grandmultiparity is a risk factor for pregnancy in this part of the world, even in the presence of reasonable antenatal care. This may be explained on the basis of the increased age of these women. Finally, we also recommend that an age-matched study needs to be undertaken in order to determine if age is an important determinant for risk factors in grandmultiparas.

Clinical and functional staging of oral submucous fibrosis

OBJECTIVE

To investigate the association of location of bands in oral submucous fibrosis and extent of mouth-opening.

DESIGN

Cross-sectional study.

SETTING

University hospital, Pakistan.

SUBJECTS

325 patients who presented with oral submucous fibrosis in Karachi between January 1992 and October 1994, of whom 288 had data sufficient for analysis.

MAIN MEASURES

Location of fibrous bands in the mouth and interincisal distance (mm).

RESULTS

All subjects with labial bands had bands in the fauces, and all but one who had labial bands also had buccal bands. All those with buccal bands also had bands in the fauces. Of those with buccal bands, 42% did not have labial bands. The proportion of patients with bands in all three sites increased from functional stage A (interincisal opening < or = 10 mm) to stage C (interincisal opening > or = 20 mm) with a simultaneous reduction in the proportion of people with bands in one or two sites (X2 = 105, df = 4, P < 0.0001).

CONCLUSIONS

Bands are common at the back of the mouth in mild cases of oral submucous fibrosis and, as the disease increases in severity, are more likely to be found anteriorly as well.

Role of intrauterine growth retardation on physical growth of Pakistani squatter children from birth to 2 years of age

A birth cohort of 727 squatter children from Karachi was followed to study growth patterns by measuring anthropometric parameters at specific ages during the first 2 years of life. The mean weight and length of the intrauterine growth retarded and appropriate for gestational age children fell below the 10th percentile of the NCHS standards after 9 months and further deteriorated in the subsequent study period. However, the intrauterine growth retarded children showed slightly higher growth velocities compared to appropriate for gestational age children in the first few months for all four measurements, but subsequently these differences in growth velocities diminished. Our results suggest that nutrition intervention strategies should begin in early pregnancy.

Risk behaviours associated with urethritis in prison inmates, Sindh

OBJECTIVE

To identify sexual risk behaviours associated with lifetime risk of urethritis in prison inmates.

DESIGN

A cross-sectional study using a pre-designed questionnaire.

SETTING

Fourteen prisons throughout the Sindh Province, Pakistan.

SUBJECTS

Three thousand three hundred ninety-five prison inmates incarcerated during July, 1994.

MAIN OUTCOME MEASURE

Lifetime risk of urethritis occurrence (whether or not the subject was ever affected with urethritis up to his present age)

RESULTS

Lifetime risk of urethritis occurrence in the study population was 20.8% (706/3395). The final multivariate logistic regression model indicated that risk behaviours associated with lifetime risk of urethritis in this population were 'sexual intercourse with a female' (adjusted OR = 2.18; 95% CI 1.60, 2.95), 'multiple female sexual partners' (adjusted OR = 1.67; 95% CI 1.28, 2.18) and 'sexual intercourse with man' (adjusted OR = 2.75; 95% CI 2.29, 3.31).

CONCLUSION

The prevalence of urethritis in this population was very high. High prevalence of various risky sexual behaviours among inmates indicates, their unawareness as to what precautions they might take to avoid risk of acquiring STDs including HIV. The study subjects meet the characteristics of a core group of STDs transmitters and provides short window of opportunity for STD/HIV control programs to intervene, while they are in detention to reduce the risk not only for this group but also for general population.

Does use of a government service depend on distance from the health facility?

To reduce mortality from common childhood illnesses such as diarrhoea and upper respiratory infections, it is important that health services are available and used appropriately. Physical accessibility to a health facility may influence its use, particularly in rural areas. We assessed whether use of government services for treatment of the three most common acute childhood illnesses (fever, diarrhoea and upper respiratory infections) was influenced by the physical accessibility of the government primary health care centres. We analyzed data from a household survey which was collected between November 1992 and January 1993, from 139 randomly selected villages located around 14 government facilities in Thatta, a rural district of Pakistan. There were 691 children under 5 years of age who suffered from the three acute illnesses; 85% of these children used either a government or a private service. Children living at less than 4 km from a government facility made 22% less use of that facility than those living 4 km or more away. After controlling for the effects of distance from a private facility and treatment cost in a multiple logistic regression model, children living less than 4 km from a government facility were no more likely to use the facility than those living 4 km or more away (Adjusted Odds Ratio: 1.01, 95% Confidence Interval: 0.68-1.50). These results suggest that factors other than distance are the primary determinants of use of government services for treating children in the Thatta district. To increase the use of government health services, policymakers should assess carefully the factors determining the use of existing facilities, before they plan the building of more health facilities. Further studies are needed to examine the management of health facilities and the clients' perception of health-care providers.

Methotrexate in rheumatoid arthritis: a 2 year experience at a university hospital in Pakistan

In this study we report our two years experience of methotrexate (MTX) in the management of rheumatoid arthritis (RA) at the Aga Khan University Hospital, Karachi. We studied the clinical course of 124 RA patients. The mean age was 44 +/- 11 years (range 19-72) and mean duration of RA was 5 +/- 4 years (range 0.3-25). Female to male ratio was 10:2.4 (100F:24M). All of them were diagnosed according to the criteria set by American Rheumatism Association. The mean value of ESR was 60 +/- 30 (Range 3-128). Fifty one percent had severe disease (> 10 joints involved and evidence of erosions and deformities). Twenty-one patients had extra-articular manifestations. None of them had received MTX previously. Their kidney and liver functions were assessed to be normal. Patients were divided into two groups. One group (n = 92) received MTX (7.5-10 mg/week) as initial treatment, while the other group (n = 32) was given other disease modifying anti-rheumatic drugs (penicillamine, salazopyrin, gold, or chloroquine) followed by MTX. Assessment of the treatment outcome and development of any adverse reactions was carried out at 3-month interval over an average period of 1 year. Assessment of the treatment outcome in the group which received MTX as initial drug revealed the response to be excellent in 13%, good in 70%, fair in 11% and variable in 4%. In the group which received MTX as second-line of therapy, 59% of the patients had the response from good to excellent, while 25% of the patients exhibited poor to fair response. Regarding side-effects of MTX treatment, 57% exhibited none, while 35% had nausea and vomiting. Alopecia was the next common toxicity in these patients. Two individuals had abnormal liver function tests (value twice more than normal), while one developed lung fibrosis. MTX despite its adverse effects in some of the patients is still an effective, well tolerated and inexpensive disease modifying drug in RA.

Spontaneous systemic anaphylaxis as an unusual presentation of hydatid cyst: report of two cases

We report two cases presenting with severe spontaneous systemic anaphylactic reaction who were subsequently found to have hydatid cyst(s) in one or more intra-abdominal organs. This unusual presentation in otherwise asymptomatic patients, without known precipitating factors, i.e., trauma, or accidental (needle aspiration or surgical) rupture of the cyst emphasizes that physicians in endemic regions should keep a high index of suspicion for the hydatid disease as a possible etiology for seemingly idiopathic anaphylactic reaction.

Is there an association between season of birth and reading disability?

Reported associations between season of birth and reading failure suggest medical causation and prevention. The relationship between season of birth and two measures of reading outcome in two cohorts of children (n1 = 2411 and n2 = 1972) was studied using chi2 tests. None was significant. Logistic regression was used to investigate the joint associations of gender, age at school entrance, and season of birth with reading outcome. A significant interaction between reading failure and age category (overage at school entrance vs correct age) by season of birth was observed. It was shown that this significant interaction was probably caused by kindergarten entrance cutoff birth dates. Although 67.8% of all overage children had summer births, only 15.3% failed in reading, which is not statistically different from the percentage of summer-born, correct-age low readers (13.6%). Results suggest that reported associations may be attributed to selective samples rather than the total population of school children who experience reading failure.

The effects of age and gender on reading achievement: implications for pediatric counseling

The hypothesis that age of school entrance and gender interact to affect academic achievement was tested on three samples of children at the end of 1st (n = 1215), 2nd (n = 1141), and 3rd grade (n = 1037). Multiple regressions of age, gender, and their interaction on reading achievement resulted in significant effects of age for each sample. However, these variables together accounted for less than 1% of the variability in reading scores at each grade. There was a significant interaction between age and gender for the 3rd grade sample. Separate gender analyses of variance by age class revealed that girls who were 6 years or older at the time of entrance achieved significantly lower than middle-entrance-age or younger girls. Contrary to popular belief, there were no significant age class effects for boys. These findings indicate that significantly more attention should be focused on the specific skills that children bring to the learning process than on their age and gender in assessing readiness. Implications for pediatric counseling are discussed.