Role of rotavirus vaccine in reducing diarrheal episodes in infants visiting private primary health care clinics in Karachi, Pakistan: A mixed-methods study

BACKGROUND

Rotavirus (RV) induced diarrhea led to hospitalization and mortality prior to the introduction of the rotavirus vaccine (RVV). The estimated RVV coverage was 86% in children less than one year of age in Pakistan.

OBJECTIVES

To determine the difference in the number of diarrheal episodes among children who received and who did not receive RVV, along with the parental and physician's perspectives on the barriers toward RV immunization in children aged less than 1 year in Karachi, Pakistan.

METHODS

A mixed-methods study design was conducted in three Primary Healthcare (PHC) private clinics located in different districts of Karachi, Pakistan. Data for RVV status and diarrheal episodes were collected, from medical records in June 2020 for children born between October 2019 to March 2020. Three In-depth Interviews (IDIs) with physicians and three focus group discussions (FGDs) with mothers were conducted for information on awareness and approach towards diarrhea, knowledge, and acceptance of RVV, and barriers towards RV immunization.

RESULTS

A total of 430 infants visited the three PHC centres coded as A (n = 144), B (n = 146), and C (n = 140). The mean age of infants was 2.6 ± 0.2 months, 49.5 % were males and 87 (20.2 %) were partial/not vaccinated for RV. Reported diarrheal episodes were 104 (24.2 %), and of these 76 (73.1 %) were partially or not vaccinated, and 83 (79.8 %) were stunted. Recorded diarrhea was significantly associated with partial/not vaccinated status (p < 0.001), stunting (p < 0.001), and by PHC centre location (p < 0.001). PHC-C had the lowest percentage of reported diarrhea, stunting, and non/partially vaccinated status. Qualitative study (FGDs) showed that mothers had lack of awareness and knowledge on the prevention of diarrhea by RVV. Physicians' IDIs pointed towards a lack of sufficient training on RVV.

CONCLUSION

Diarrheal episodes in infants were associated with partial or unvaccinated for RVV, low nutritional status, and areas of residence. Low levels of knowledge and awareness in caretakers and lack of training for RVV in PHC physicians were perceived as barriers in controlling diarrheal diseases.

"Caught In Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry

BACKGROUND

Despite known adverse impacts on patients and health systems, 'incentive-linked prescribing', which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors), using Pakistan as a case study.

METHODS

Our mixed-methods study synthesised insights from a survey of 419 systematically samples private doctors and 68 semi-structured interviews with private doctors (n=28), pharmaceutical sales representatives (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered private doctors within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach.

RESULTS

Our survey showed that 90% of private doctors met pharmaceutical sales representatives weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate and an over-saturated pharmaceutical market.

CONCLUSION

Regular interactions between pharmaceutical companies and private doctors are normalised in our study setting, and progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and the pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policymakers concerned about curtailing growth of the pharmaceutical industry.

What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan

OBJECTIVES

Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan.

METHODS

We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes.

RESULTS

We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later.

CONCLUSIONS

The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Conflict Of Interests Driven By Pharmaceutical Incentivisation: Risks To The Medical Fraternity In Pakistan

Conflict of interest (COI) in medical practice, and how it affects healthcare delivery and quality, is a poorly studied issue in Pakistan. COI can broadly be defined as a situation that arises when the opportunity for personal gain takes primacy over an individual’s professional responsibilities.1 In medicine, trust is the cornerstone of the doctor-patient relationship. Doctors hold an authoritative position based on their knowledge and expertise and are entrusted by the healthcare system and patients to put the patients’ best interests first. This means that to maintain trust, not only doctors are required to appropriately diagnose, treat and/or manage patients’ illnesses, but also consider their social and financial circumstances. In this editorial, we draw attention to a prime example of how COI manifests in medical practice as a result of the interactions between doctors and pharmaceutical sales representatives (PSRs). While PSRs are a source of knowledge on existing and new pharmaceutical products, this relationship can turn into an apparatus of financial corruption, when, in their efforts to maximise profits, PSRs incentivise doctors for prescribing. We refer to this as incentive-linked prescribing (ILP) whereby doctors accept some form of incentive in exchange for prescribing to meet pharmaceutical sales targets, without considering the added financial burden on patients and adverse health outcomes. In 2021, the Drug Regulatory Authority of Pakistan (DRAP) published rules by which pharmaceutical companies are prohibited to offer incentives to doctors for prescriptions, however, these rules are poorly enforced.2 The absence of concrete legislation, clear-cut guidelines, sound monitoring, and regulation mechanism paves the way for the establishment of the unethical profit-driven relationship between doctors and the pharmaceutical industry. Consequences of ILP to patients, doctors, and the healthcare system There is growing attention to ILP and its consequences to medical practice and public health in Pakistan. Research has shed light on the well-entrenched influence of PSRs on physicians prescribing practices.3 This level of influence is achieved with the help of incentives, which foster dependent relationships between physicians and the pharmaceutical industry. Alarmingly, much of the research concludes that ILP has become normalised within the medical fraternity and how they interact with pharmaceutical companies.3,4 ILP can lead to several negative consequences for patients, doctors, and the healthcare system, and it is critical that doctors are made aware of these consequences. Patients may be aware of the unethical profit-driven relationship between doctors and pharmaceutical companies, and for this reason, lose trust in doctors. Doctors may prescribe most costly and/or unnecessary medications than what would otherwise have been prescribed. This can put patients under additional financial pressure and subject them to potential adverse health outcomes. Indeed, ILP is one of the largest contributors to the consumption of antibiotics in Pakistan, in addition to over-the-counter medications.5 The abuse and misuse of antibiotics is the leading reason for antimicrobial resistance (AMR) worldwide, which is one of the top ten threats to global health and is estimated to cause ten million deaths each year by 2030.6 These consequences have significant negative implications for the healthcare system, in terms of burden of disease, financing, and quality of care provided. Continued.....

Feasibility of a peer-supported, WhatsApp-assisted, lifestyle modification intervention for weight reduction among adults in an urban slum of Karachi, Pakistan: a mixed-methods, single-group, pretest-post-test, quasi-experimental study

OBJECTIVES

This pilot study assessed whether a peer-supported, WhatsApp-assisted lifestyle modification intervention for weight reduction is feasible to execute a definitive trial.

DESIGN

A mixed-methods, single group, pretest and post-test, quasi-experimental study.

SETTING

Azam Basti, an urban slum in Karachi, Pakistan.

PARTICIPANTS

Fifty participants (males and females aged 20-60) with a body mass index of >23 kg/m2, along with their nominated peers from the same family.

INTERVENTION

Using motivational interviewing techniques, a trained nutritionist delivered the lifestyle modification intervention to the participants and peers for 3 days after the baseline assessment and then once monthly for 1 year. The intervention was delivered in groups using WhatsApp voice calls. The education sessions mainly focused on dietary modifications, physical activity advice and peer-support assignments to achieve a 5% wt loss from the participant's initial body weight.

OUTCOMES

The feasibility measures included screening, recruitment, retention and monthly interview response rates. At 1 year, in-depth interviews (IDIs) with participants and peers were conducted to explore the facilitators, barriers, acceptability and experiences of the intervention. Changes in weight, calorie intake/day and calorie expenditure/day were also assessed.

RESULTS

The recruitment and retention rates were 32% (n=50/156) and 78% (n=39/50), respectively, while the response rate for monthly interviews ranged between 66% (n=33) and 94% (n=47). The mean weight loss at 1 year was 2.2 kg, and the reduction in mean calorie intake was 386 kcal/day. There were no changes in the mean calorie expenditure. During the IDIs, participants and peers reported intervention via WhatsApp and peer support as convenient, flexible and supportive.

CONCLUSIONS

The quantitative and qualitative findings of the current pilot study support the scale-up of this work with minor modifications to the screening method as well as close monitoring and motivational interviewing to improve adherence in terms of physical activity.

TRIAL REGISTRATION NUMBER

NCT05928338.

Socioecological factors linked with pharmaceutical incentive-driven prescribing in Pakistan

Pharmaceutical marketing through financial incentivisation to general practitioners (GPs) is a poorly studied health system problem in Pakistan. Pharmaceutical incentivisation is seen to be distorting GPs prescribing behaviour that can compromise the health and well-being of patients. We draw on a conceptual framework outlined in the ecological system theory to identify multiple factors linked with pharmaceutical incentivisation to GPs in Pakistan. We conducted qualitative interviews with 28 policy actors to seek their views on the health system dynamics, how they sustain pharmaceutical incentivisation and their effect on the quality of care. Our analysis revealed four interlinked factors operating at different levels and how they collectively contribute to pharmaceutical incentivisation. In addition to influences such as the increasing family needs and peers' financial success, sometimes GPs may naturally be inclined to maximise incomes by engaging in pharmaceutical incentivisation. On other hand, the pharmaceutical market dynamics that involve that competition underpinned by a profit-maximisation mindset enable pharmaceutical companies to meet GPs' desires/needs in return for prescribing their products. Inadequate monitoring and health regulations may further permit the pharmaceutical industry and GPs to sustain the incentive-driven relationship. Our findings have important implications for potential health reforms such as introducing regulatory controls, and appropriate monitoring and regulation of the private health sector, required to address pharmaceutical incentivisation to GPs.

Exploring stakeholders' experiences and perceptions regarding barriers to effective surveillance of communicable diseases in a rural district of Pakistan: a qualitative study

OBJECTIVE

To explore the experiences and perceptions of health system stakeholders of a rural district of Sindh, Pakistan regarding the barriers to effective surveillance of communicable diseases.

DESIGN

This qualitative descriptive exploratory design comprised in-depth interviews. Both inductive and deductive thematic analysis was applied to identify key themes from the data.

SETTINGS

The study was conducted in public sector healthcare facilities and the district health office of the rural district of Thatta, in Sindh province, Pakistan.

PARTICIPANTS

Fifteen healthcare managers and healthcare providers working in the eight public sector primary and secondary healthcare facilities were interviewed using an open-ended in-depth interview guide.

RESULTS

Key themes that emerged from the data were: poor governance and absence of surveillance policy framework; fragmentation in the health system leading to lack of uniform reporting; inadequate (human) resources that weakened the infrastructure for disease surveillance; hospital-based reporting of cases that led to a predominantly passive surveillance system; paper-based surveillance system as the key determinant of delayed reporting; non-utilisation of surveillance data for decision making; absence of local laboratory capacity to complement the detection of disease outbreaks and lack of private sector integration in disease surveillance.

CONCLUSIONS

Poor governance and lack of policy framework were perceived to be responsible for weak surveillance infrastructure. Resource deficiencies including inadequate human resource, paper-based reporting and the absence of local laboratory capacity were considered to result in delayed, poor quality and incomplete reporting. The lack of private sector engagement was identified as a major gap.

Impact of a multifaceted intervention on physicians' knowledge, attitudes and practices in relation to pharmaceutical incentivisation: protocol for a randomised control trial

INTRODUCTION

In settings where the private sector constitutes a larger part of the health system, profit-gathering can take primacy over patients' well-being. In their interactions with pharmaceutical companies, private general practitioners (GPs) can experience the conflict of interest (COI), a situation whereby the impartiality of GPs' professional decision making may be influenced by secondary interests such as financial gains from prescribing specific pharmaceutical brands.

METHODS AND ANALYSIS

This study is a randomised controlled trial to assess the impact of a multifaceted intervention on GPs' medical practice. The study sample consists of 419 registered GPs who own/work in private clinics and will be randomly assigned to intervention and control groups. The intervention group GPs will be exposed to emotive and educational seminars on medical ethics, whereas control group GPs will be given seminars on general medical topics. The primary outcome measure will be GPs' prescribing practices, whereas the secondary outcome measures will be their knowledge and attitudes regarding COI that arises from pharmaceutical incentivisation. In addition to a novel standardised pharmaceutical representatives (SPSR) method, in which field researchers will simulate pharmaceutical marketing with GPs, presurvey and postsurvey, and qualitative interviewing will be performed to collect data on GPs' knowledge, attitudes and practices in relation to COI linked with pharmaceutical incentives. Univariate and multivariate statistical analyses will be performed to measure a change in GPs' knowledge, attitudes and practices, while qualitative analysis will add to our understanding of the quantitative SPSR data.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Pakistan National Bioethics Committee (# 4-87/NBC-582/21/1364), the Aga Khan University (# 2020-4759-1129) and the London School of Hygiene and Tropical Medicine (# 26506). We will release results within 6-9 months of the study's completion.

TRIAL REGISTRATION NUMBER

ISRCTN12294839.

The Impact of Disease Control Measures on the Spread of COVID-19 in the Province of Sindh, Pakistan

The province of Sindh reported the first COVID-19 case in Pakistan on 26th February 2020. The Government of Sindh has employed numerous control measures to limit its spread. However, for low-and middle-income countries such as Pakistan, the management protocols for controlling a pandemic are not always as definitive as they would be in other developed nations. Given the dire socio-economic conditions of Sindh, continuation of province-wise lockdowns may inadvertently cause a potential economic breakdown. By using a data driven SEIR modelling framework, this paper describes the evolution of the epidemic projections because of government control measures. The data from reported COVID-19 prevalence and google mobility is used to parameterize the model at different time points. These time points correspond to the government's call for advice on the prerequisite actions required to curtail the spread of COVID-19 in Sindh. Our model predicted the epidemic peak to occur by 18th June 2020 with approximately 3500 reported cases at that peak, this projection correlated with the actual recorded peak during the first wave of the disease in Sindh. The impact of the governmental control actions and religious ceremonies on the epidemic profile during this first wave of COVID-19 are clearly reflected in the model outcomes through variations in the epidemic peaks. We also report these variations by displaying the trajectory of the epidemics had the control measures been guided differently; the epidemic peak may have occurred as early as the end of May 2020 with approximately 5000 reported cases per day had there been no control measures and as late as August 2020 with only around 2000 cases at the peak had the lockdown continued, nearly flattening the epidemic curve.

Determinants of hepatitis B vaccination status in health care workers of two secondary care hospitals of Sindh, Pakistan: a cross-sectional study

BACKGROUND

Health care workers (HCWs) are at high risk of Hepatitis B virus (HBV) transmission. Hepatitis B vaccination is effective in protecting against HBV infection. Different factors influence HCW vaccination status such as lack of knowledge & awareness, cost, availability, and hesitancy. This study aimed to determine Hepatitis B vaccination status and factors influencing vaccination status in HCWs of two secondary care hospitals at Sindh, Pakistan.

METHODS

A cross-sectional study was conducted in two secondary care hospitals of Sindh, Pakistan. A total of 252 doctors, nurses, laboratory, and other HCWs were asked about the HBV vaccination coverage using a structured tool. Multivariable ordinal logistic regression was used to determine the association of participant's characteristics, vaccination knowledge with HBV vaccination coverage considering p-value ≤0.05 significant. Odds ratios with 95% confidence interval (CI) were reported.

RESULTS

Our study found that 64.9% doctors, 75.18% nurses, 58.3% allied HCWs, 40.0% laboratory staff, and 70.8% housekeeping staff were completely vaccinated. HCWs stated job entry requirement as the primary reason for complete vaccination (AOR 4.6, 95% CI 1.5-5.3) from the disease. HCWs working in Aga Khan hospital Karachi and who have received vaccination before working in that hospital had four-time higher odds for hepatitis B vaccination (AOR 4.3, 95% CI 1.7-4.9).

CONCLUSION

Two-third of the HCWs were completely vaccinated in secondary care hospitals in Sindh, Pakistan. Hepatitis B vaccination should be made a job entry requirement to achieve more complete vaccination numbers. Vaccination policies require to implement for all part-timers and full-timer health care workers.

Phylogenetic and Drug-Resistance Analysis of HIV-1 Sequences From an Extensive Paediatric HIV-1 Outbreak in Larkana, Pakistan

Introduction

In April 2019, an HIV-1 outbreak among children occurred in Larkana, Pakistan, affecting more than a thousand children. It was assumed that the outbreak originated from a single source, namely a doctor at a private health facility. In this study, we performed subtype distribution, phylogenetic and drug-resistance analysis of HIV-1 sequences from 2019 outbreak in Larkana, Pakistan.

Methods

A total of 401 blood samples were collected between April–June 2019, from children infected with HIV-1 aged 0–15 years recruited into a case-control study to investigate the risk factors for HIV-1 transmission. Partial HIV-1 pol sequences were generated from 344 blood plasma samples to determine HIV-1 subtype and drug resistance mutations (DRM). Maximum-likelihood phylogenetics based on outbreak and reference sequences was used to identify transmission clusters and assess the relationship between outbreak and key population sequences between and within the determined clusters. Bayesian analysis was employed to identify the time to the most recent common recent ancestor (tMRCA) of the main Pakistani clusters.

Results

The HIV-1 circulating recombinant form (CRF) 02_AG and subtype A1 were most common among the outbreak sequences. Of the treatment-naïve participants, the two most common mutations were RT: E138A (8%) and RT: K219Q (8%). Four supported clusters within the outbreak were identified, and the median tMRCAs of the Larkana outbreak sequences were estimated to 2016 for both the CRF02_AG and the subtype A1 clusters. Furthermore, outbreak sequences exhibited no phylogenetic mixing with sequences from other high-risk groups of Pakistan.

Conclusion

The presence of multiple clusters indicated a multi-source outbreak, rather than a single source outbreak from a single health practitioner as previously suggested. The multiple introductions were likely a consequence of ongoing transmission within the high-risk groups of Larkana, and it is possible that the so-called Larkana strain was introduced into the general population through poor infection prevention control practices in healthcare settings. The study highlights the need to scale up HIV-1 prevention programmes among key population groups and improving infection prevention control in Pakistan.

Factors associated with HIV infection among children in Larkana District, Pakistan: a matched case-control study

BACKGROUND

In April, 2019, an HIV outbreak predominantly affecting children occurred in Larkana District, Sindh, Pakistan. By December, 2019, 881 (4·0%) of 21 962 children screened for HIV had tested positive. We aimed to assess factors associated with HIV infection in this outbreak.

METHODS

In this individually matched case-control study, we sampled 406 cases (individuals aged <16 years who had registered for paediatric HIV care at the HIV Treatment Centre at Shaikh Zayed Children's Hospital in Larkana City, Pakistan) and 406 controls (individuals without HIV matched by age, sex, and neighbourhood residence, recruited through doorknocking at houses adjacent to case participants). An interviewer-administered questionnaire was used to collect data on possible risk factors for HIV acquisition and a blood sample was collected from all participants for hepatitis B and hepatitis C serology. Mothers of all participants underwent HIV testing. Odds ratios were estimated using conditional logistic regression to assess factors associated with HIV infection.

FINDINGS

406 case-control pairs were recruited between July 3 and Dec 26, 2019. Five pairs were excluded (three pairs had an age mismatch and two pairs were duplicate cases) and 401 were analysed. The prevalence of hepatitis B surface antigen was 18·2% (95% CI 14·5-22·3) among cases and 5·2% (3·3-7·9) among controls, and the prevalence of hepatitis C antibodies was 6·5% (95% CI 4·3-9·4) among cases and 1·0% (0·3-2·5) among controls. 28 (7%) of 397 mothers of cases for whom we had data, and no mothers of 394 controls, were HIV positive. In the 6 months before recruitment, 226 (56%) of 401 cases and 32 (8%) of 401 controls reported having more than ten injections, and 291 (73%) cases and 78 (19%) controls had received an intravenous infusion. At least one blood transfusion was reported in 56 (14%) cases and three (1%) controls in the past 2 years. HIV infection was associated with a history of more injections and infusions (adjusted odds ratio 1·63; 95% CI 1·30-2·04, p<0·0001), blood transfusion (336·75; 23·69-4787·01, p<0·0001), surgery (399·75, 13·99-11 419·39, p=0·0005), the child's mother being HIV positive or having died (3·13, 1·20-8·20, p=0·020), and increased frequency of private clinic (p<0·0001) and government hospital visits (p<0·0001), adjusting for confounders.

INTERPRETATION

The predominant mode of HIV transmission in this outbreak was parenteral, probably due to unsafe injection practices and poor blood safety practices. General practitioners across Pakistan need training and systems support in reducing injection use, and in providing safe injections and transfusions only when necessary.

FUNDING

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

Depression among adult patients with primary brain tumour: a cross-sectional study of risk factors in a low-middle-income country

OBJECTIVE

The prevalence of depression among patients with primary brain tumour ranges from 15% to 40% globally. Several individual and clinical factors contribute to the development of depression. However, their association with depression in Pakistani setting has not yet been assessed. Thus, we aim to study the factors associated with depression among adult patients with primary brain tumour at a tertiary care hospital in Karachi, Pakistan.

STUDY DESIGN

A prospective cross-sectional study.

SETTING

This study was conducted at a tertiary care hospital of Karachi, Pakistan.

PARTICIPANTS

This study included 132 patients with confirmed diagnosis of primary brain tumour (initially diagnosed on MRI of the brain with contrast and later confirmed on histology of surgical specimen) in various stages of treatment.

PRIMARY OUTCOME

The primary outcome of this study was to assess depression and its associated factors among adult patients with primary brain tumour. Depression was assessed using a validated screening tool Patient Health Questionnaire-9 (PHQ-9). Scores of 10-27 on PHQ-9 were indicative of screen positive for depressive symptoms. A set of the structured pre-tested questions was used to evaluate patient-related, tumor-related and treatment-related factors.

RESULTS

Fifty-one (39%, CI: 33.33-46.94) patients in our study screened positive for depressive symptoms on PHQ-9. There was a significant association between depressive symptoms and Karnofsky Performance Scores (KPS) (prevalence ratio: 3.25 and CI: 1.87-5.62) after controlling covariates. Propensity scores predicted a positive association between KPS (functional status) and unemployment, treatment stage, and tumour recurrence. Tumor-related and treatment-related factors including tumour grade, location, type and hemispheric lateralisation were found insignificant.

CONCLUSION

Depression is common in patients with primary brain tumour. Impaired functional status has a direct impact on depression in these patients. Incorporating the psychosocial domain earlier in the course of treatment needs to be considered for better neuro-oncology management of patients with primary brain tumour.

Lifestyle changes and glycemic control in type 1 diabetes mellitus: a trial protocol with factorial design approach

BACKGROUND

Type 1 diabetes (T1D) has been increasing globally over the past three decades. Self-monitoring of blood glucose is a challenge in both developed as well as developing countries. Self-management guidelines include maintaining logbooks for blood glucose, physical activity, and dietary intake that affect glycated hemoglobin (HbA1c) and a multitude of life-threatening acute complications. Innovative, cost-effective interventions along with beneficial lifestyle modifications can improve home-based self-monitoring of blood glucose in T1D patients. The overall objective of this study is to evaluate the relationship between maintaining log books for blood glucose levels, reinforcement by e-messages, and/or daily step count and changes in HbA1c.

METHODS/DESIGN

A randomized controlled trial will enroll participants aged 15 years and above in four groups. Each group of 30 participants will be working with a newly designed standard log book for documenting their blood glucose. The first group will be entirely on routine clinical care, the second group will be on routine care and will receive an additional e-device for recording step count (fit bit), the third group will receive routine care and daily motivational e-messages to maintain the log book, and the fourth group along with routine care will receive an e-device for measuring step count (fit bit) and e-messages about maintaining the log book. Patients will be enrolled from pediatric and endocrine clinics of a tertiary care hospital in Karachi. All groups will be followed up for a period of 6 months to evaluate outcomes. Log book data will be obtained every 3 months electronically or during a patient's clinic visit. HbA1c as a main outcome will be measured at baseline and will be evaluated twice every 3 months. A baseline questionnaire will determine the socio-demographic, nutritional, and physical activity profile of patients. Clinical information for T1D and other co-morbidities for age of onset, duration, complications, hospitalizations, habits for managing T1D, and other lifestyle characteristics will be ascertained. Behavioral modifications for maintaining daily log books as a routine, following e-messages alone, fit bit alone, or e-messages plus using fit bit will be assessed for changes in HbA1c using a generalized estimated equation.

DISCUSSION

The proposed interventions will help identify whether maintaining log books for blood glucose, motivational e-messages, and/or daily step count will reduce HbA1c levels.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03864991. March 6, 2019.

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak

BACKGROUND

In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care.

METHODS

In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ² tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV.

FINDINGS

Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions.

INTERPRETATION

This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies.

FUNDING

None.

Sedentary lifestyle and Framingham risk scores: a population-based study in Riyadh city, Saudi Arabia

BACKGROUND

Studies from Saudi Arabia have reported a continued increase in the prevalence of cardiovascular diseases and their associated risk factors. The objective of this study was to measure the gender differences in the cardiovascular disease (CVD) risk based on Framingham risk scores (FRS) and to explore the association of FRS with sedentary life style including physical inactivity, sitting time and central obesity among Saudi adults.

METHODS

A cross-sectional survey was conducted on 2997 Saudi adults (males = 968, females = 2029) selected from 18 primary health care centres in Riyadh city, from December 2014 to August 2015. A detailed interview that evaluated lifestyle and past medical history was conducted; furthermore, anthropometric measurements and blood samples were collected for lipid profiling. The FRS were calculated based on the age, gender, systolic blood pressure, treatment for hypertension, diabetes, smoking status, total blood cholesterol and high-density lipoprotein levels. These scores were categorized into low risk (FRS < 10) and high/intermediate risk (≥10). A multivariable logistic regression analysis was performed.

RESULTS

The mean (±SD) age of the males and females was 43.1(±11.7) vs 43.8(±10.9) years (p = 0.07), respectively. The number of Saudi male participants with intermediate-to-high FRS scores (≥10) was almost twice that of females (males 33% vs 17%). The multivariable logistic regression model after adjusting for education level and housing type, found that low physical activity (aOR & 95%CI for males 2.91 (1.45, 5.80); females 1.38 (1.06, 1.81); prolonged sitting time (aOR &95%CI for males 1.36 (0.98, 1.90) females 1.58 (1.20, 2.07), high central obesity (defined as waist circumference in males > 102 cms, and females > 88 cms) (aOR & 95%CI for males 2.38 (1.67, 3.41); females 3.35 (1.92, 5.87) were associated with high/ intermediate risk for CVD.

CONCLUSIONS

A significant percentage of Saudi population revealed FRS ≥10. Females beyond the age of 50 were found to have a higher prevalence for CVD risk compared with males of the same age group. Modifiable risk factors like low physical activity, prolonged sitting time and central obesity have strong implications for primary prevention and management services that can change the risk profile of the Saudi population.

Medical Doctors' Offline Computer-Assisted Digital Education: Systematic Review by the Digital Health Education Collaboration

Background

The widening gap between innovations in the medical field and the dissemination of such information to doctors may affect the quality of care. Offline computer-based digital education (OCDE) may be a potential solution to overcoming the geographical, financial, and temporal obstacles faced by doctors.

Objective

The objectives of this systematic review were to evaluate the effectiveness of OCDE compared with face-to-face learning, no intervention, or other types of digital learning for improving medical doctors’ knowledge, cognitive skills, and patient-related outcomes. Secondary objectives were to assess the cost-effectiveness (CE) of OCDE and any adverse effects.

Methods

We searched major bibliographic databases from 1990 to August 2017 to identify relevant articles and followed the Cochrane methodology for systematic reviews of intervention.

Results

Overall, 27 randomized controlled trials (RCTs), 1 cluster RCT (cRCT), and 1 quasi-RCT were included in this review. The total number of participants was 1690 in addition to the cRCT, which included 24 practices. Due to the heterogeneity of the participants, interventions, and outcomes, meta-analysis was not feasible, and the results were presented as narrative summary.

Compared with face-to-face learning, the effect of OCDE on knowledge gain is uncertain (ratio of the means [RM] range 0.95-1.17; 8 studies, 495 participants; very low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 0.1-0.9; 8 studies, 375 participants; very low grade of evidence). OCDE may have little or no effect on patients’ outcome compared with face-to-face education (2 studies, 62 participants; low grade of evidence).

Compared with no intervention, OCDE may improve knowledge gain (RM range 1.36-0.98; 4 studies, 401 participants; low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 1.1-1.15; 4 trials, 495 participants; very low grade of evidence). One cRCT, involving 24 practices, investigated patients’ outcome in this comparison and showed no difference between the 2 groups with low-grade evidence.

Compared with text-based learning, the effect of OCDE on cognitive skills gain is uncertain (RM range 0.91-1.46; 3 trials with 4 interventions; 68 participants; very low-grade evidence). No study in this comparison investigated knowledge gain or patients’ outcomes.

One study assessed the CE and showed that OCDE was cost-effective when compared with face-to-face learning if the cost is less than or equal to Can $200. No trial evaluated the adverse effect of OCDE.

Conclusions

The effect of OCDE compared with other methods of education on medical doctors’ knowledge and cognitive skill gain is uncertain. OCDE may improve doctors’ knowledge compared with no intervention but its effect on doctors’ cognitive skills is uncertain. OCDE may have little or no effect in improving patients’ outcome.

Depression literacy in women attending university hospital clinics in Riyadh Saudi Arabia

BACKGROUND

Depression literacy in general population constitutes an ability to understand depression, with knowledge of disease, its risk factors and symptoms. High levels of depression literacy promote early intervention, potentially reducing related disability.

AIM

This study investigated the depression literacy in women visitors to clinics of a tertiary care hospital in Riyadh, Saudi Arabia.

METHODS

Women of 18 and more years were surveyed during their visit to primary and other healthcare clinics of a public hospital in Riyadh. Knowledge on depression symptoms, causes and management approaches identified depression literate women scoring more than 30 points on a 42-item tool.

RESULTS

Of the 409 participants, 65.5% were depression literate, 50% educated as college and above, 64.3% married, 50.7% housewives, 62.4% reported use of multiple information sources (range, 0-8) and had a mean age of 34.9 (standard deviation ( SD), 12.4) years. In a logistic regression model, participants scoring less than 30 for depression literacy were significantly associated with women having less than college-level education, divorced marital status and use of decreasing number of learning resources.

CONCLUSION

Women with low education divorced; using fewer information sources need specific considerations by healthcare providers for assessment of depressive disorders in this setting.

Coverage and predictors of routine immunization among 12-23 months old children in disaster affected communities in Pakistan

OBJECTIVES

We aimed this study to determine the relationship of various factors related to poor immunization in children in an earthquake affected community.

MATERIALS AND METHODS

We conducted this cross-sectional study during 2007-2008 in Muzaffarabad district of Pakistani side of Kashmir. We selected 43 villages as clusters and in the second, 860 children between 12 and 24 months were selected from households through systematic sampling. Mothers of the eligible children were interviewed with a questionnaire. Logistic regression analysis was run to measure the association of various factors with appropriate immunization status of the children.

RESULTS

We found that 74% of children had completed their required doses of routine immunization. There were greater odds of a child being unvaccinated if the family lived at a distance that was to be covered in more than 10 min by any transport (odds ratio [OR]: 1.12, confidence interval [CI]: 1.08-1.17), mother of the child was not educated (OR:2.4, 1.3-4.4), child belonged to a low socioeconomic status (OR:3.5, CI: 2.1-6.3), family had any challenge or situation that where they could not take the child to a health facility for vaccination (OR: 2.3, CI: 1.4-3.7) and for a female child that belonged to minority ethnic group (OR: 1.7, CI: 1.0-2.5).

CONCLUSION

Improvement in access of communities, especially of minority and poor in disaster-stricken, to immunization services and female education and awareness about the need for immunization in children could play a role in improving immunization coverage in such settings.

Childhood and adolescent obesity: Primary Health Care Physicians' perspectives from Riyadh, Saudi Arabia

BACKGROUND & OBJECTIVES

Primary health care (PHC) physicians are foremost to confront childhood and adolescent obesity. Our objective was to evaluate PHC Physicians perspectives for managing overweight/obesity in children and adolescents.

METHODS

PHC services from eight public hospitals in Riyadh participated. A self-administered tool maintaining anonymity evaluated facilitators and barriers for managing overweight/obese children and adolescent patients. Physicians who 'always' recommended weight management for an overweight / obese patient during past year, by involving patient, parents, and others were classified as having positive and appropriate practice.

RESULTS

Of the 58 respondents, 51.7% had appropriate practices. Lack of patient motivation (82.2%), and parental involvement (70.7%) were the major barriers. Physicians with appropriate practices differed in perspectives from those with less appropriate practices by attending continued education forums (p<0.026), referring patients to sub-specialty (p< 0.041), clinical knowledge (p<0.039), convinced on interventions (p<0.017), low concern for precipitating eating disorders (p<0.019), comfortable in examining obese patients (p<0.020), and considered patient's readiness for weight change (p< 0.007).

CONCLUSION

Efforts are needed to equip PHC physicians in managing overweight and obesity in Saudi children and adolescents.

Barriers and Facilitators of Compliance with Universal Precautions at First Level Health Facilities in Northern Rural Pakistan

AIM

We assessed the compliance at first level care facilities (FLCF) with universal precautions (UP) and its behavioral predictors using Health Belief Model (HBM).

METHODS

A sample of FLCF from public clinic (PC), privately owned licensed practitioners' clinic (LPC) and non-licensed practitioners' clinic (NLPC) was obtained. Health Care Workers (HCW) who diagnose and prescribe medication was termed as Prescriber and that carries out prescriber's order was defined Assistant. Compliance to UP was measured on 11 items Likert scale. HCW responded "always" or "often" to all items of UP were added to compute a binary variable of overall compliance. We used linear regression to assess association between HBM and UP score.

RESULTS

We interviewed 485 HCW (75% prescribers) from 365 clinics; mean age 38±10.4 years. Overall, compliance to UP was 6.6%; 11.6% LPC, 5.3% PC, and 4.4% NLPC. Prescribers were less compliant than Assistants. Compliance with not recapping contaminated needle was poor (PC=32%, LPC=33%, NLPC=15%). Compliance with wearing gloves during blood or body fluid exposure was lowest (30%) at PC. Modes of transmission knowledge, self-efficacy and perceived benefits of safe practice, and susceptibility to blood borne infections were positively associated with UP score.

CONCLUSION

Higher perception of barriers and severity of blood borne infection result in lower compliance.

Correlates of cardiovascular disease risk scores in women in Riyadh, Kingdom of Saudi Arabia

Saudi Arabia has a high prevalence of obesity and physical inactivity. We measured cardiovascular (CVD) risk scores and determined the factors associated with them in women in Riyadh, Saudi Arabia. A cross-sectional study using a self-administered questionnaire was conducted on 291 women aged ≥ 30 years. Information was collected on socio-demographics and physical health status. Anthropometric and blood pressure measurements were taken. Physical activity was measured using Kaiser's Physical Activity Survey and Godin's Leisure Time Exercise questionnaire. CVD risk scores were calculated using the non-laboratory-based Framingham Risk (FRS) prediction model for primary care. FRS scores ranged from 0.50 to 21.9. A total of 2.7% (n = 8) of women had a high FRS score (>20), 5.5% (n = 16) had intermediate scores (11-20), and 91.8% (n = 267) of women had low scores (<10) CVD risk scores. Multiple linear regression results indicated that a one-unit change in physical activity (household/caregiver index), strenuous exercise, waist circumference, number of children, television watching, and knee pain were significantly associated with -0.20 (p < .01), -0.12 (p = .03), 0.19 (p = .001), 0.29 (p < .01), 0.13 (p = .04), and 0.11 (p = .05) unit change in CVD risk scores, respectively. Household activities and strenuous exercise had a protective role in females in relation to CVD risk. Programs recommending physical activity at all levels should be encouraged.

Determinants of severity of menopausal symptoms among Saudi women in Riyadh city

OBJECTIVE

To determine the relationship between sociodemographic, reproductive and lifestyle factors and the severity of menopausal symptoms among Saudi women attending a university hospital in Riyadh city.

METHODS

A cross-sectional survey was carried out during 2010 in Riyadh city. Women aged > 40 years attending or accompanying their relatives in outpatient clinics in King Khalid University Hospital were invited to participate in the study. The English version of the Menopause Rating Scale (MRS) was used to assess the severity of menopausal symptoms after translation and validation on a sample of 30 women.

RESULTS

A total of 490 women were included. Severe urogenital symptoms were more common among housewives compared to working women (odds ratio (OR) 2.27, 95% confidence interval (CI) 1.12-4.68) and women living in apartments or small houses compared to women living in villas (OR 1.70, 95% CI 1.90-2.64). Nulliparous women had more severe somatic symptoms compared to those who had been pregnant (OR 2.83, 95% CI 1.10-7.69). Women who exercised regularly were less likely to experience severe somatic and urogenital symptoms (OR 0.57, 95% CI 0.37-0.86; OR 0.65, 95% CI 0.44-0.98, respectively). Obese women experienced more severe psychosomatic symptoms compared to those of normal body mass index (OR 2.01, 95% CI 0.96-4.93).

CONCLUSION

Women who are housewives, living in apartments, not exercising regularly and obese are more likely to suffer from severe symptoms of menopause.

Health belief model to predict sharps injuries among health care workers at first level care facilities in rural Pakistan

BACKGROUND

We assessed the frequency and predictors of sharp injuries (SIs) among health care workers (HCWs) at first level care facilities (FLCF) in rural Pakistan.

METHOD

HCWs working at public clinic (PC), privately owned licensed practitioners' clinic (LPC) and non-licensed practitioners' clinic(NLC) were interviewed on universal precautions (UPs) and constructs of health belief model (HBM) to assess their association with SIs through negative-binomial regression.

RESULTS

From 365 clinics, 485 HCWs were interviewed. Overall annual rate of SIs was 192/100 HCWs/year; 78/100 HCWs among licensed prescribers, 191/100 HCWs among non-licensed prescribers, 248/100 HCWs among qualified assistants, and 321/100 HCWs among non-qualified assistants. Increasing knowledge score about bloodborne pathogens (BBPs) transmission (rate-ratio (RR): 0.93; 95%CI: 0.89-0.96), fewer years of work experience, being a non-licensed prescriber (RR: 2.02; 95%CI: 1.36-2.98) licensed (RR: 2.86; 9%CI: 1.81-4.51) or non-licensed assistant (RR: 2.78; 95%CI: 1.72-4.47) compared to a licensed prescriber, perceived barriers (RR: 1.06; 95%CI: 1.03-1.08), and compliance with UPs scores (RR: 0.93; 95%CI: 0.87-0.97) were significant predictors of SIs.

CONCLUSION

Improved knowledge about BBPs, compliance with UPs and reduced barriers to follow UPs could reduce SIs to HCWs.

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

BACKGROUND

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

METHODS

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

RESULTS

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

CONCLUSION

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Extent of liver inflammation in predicting response to interferon α & Ribavirin in chronic hepatitis C patients: a cohort study

Background

Liver inflammation due to HCV infection leads to fibrosis, which is an independent predictor of treatment response to interferon therapy in Chronic Hepatitis C (CHC) patients. This relationship has not been studied for liver inflammation on pretreatment liver biopsy and End of Treatment Response (ETR). ALT is a less invasive test than liver biopsy for measuring liver inflammation. Aim of this study was to compare ETR to Interferon α (recombinant Interferon) & Ribavirin in CHC patients having higher and lower grades of liver inflammation and to determine the diagnostic accuracy of pretreatment ALT for grades of liver inflammation.

Methods

A retrospective cohort of 876 naïve CHC patients, who completed Interferon α & Ribavirin for 24 weeks, was studied for ETR. Pretreatment grade of inflammation on liver biopsy was taken as the exposure variable. It was classified as high if there was moderate or severe and low if there was minimal or mild. Multivariable logistic regression modeling was performed. Diagnostic accuracy of pretreatment ALT for liver inflammation grades was determined by computing Area Under the Receiver Operator Curve (AUROC).

Results

Of all patients, 672 having diagnostic liver biopsy and ETR available were analyzed. Among them, 103 had high and 569 had low grades of liver inflammation. Mean age was 36.9 (SD 9.1) years, with patients with high grades being older than those with low grades inflammation (p = 0.03). High grades of liver inflammation was associated with ETR (RR 1.17, 95% CI 1.12–1.18) adjusting for age, Total Leukocyte count (TLC) and pretreatment levels of ALT, irrespective of liver fibrosis. This relation remained significant for ‘bridging fibrosis and cirrhosis’ and not for ‘no’ or ‘portal fibrosis’. AUROC of pretreatment ALT for males and females was moderately accurate for severe inflammation compared to minimal inflammation and less accurate for high grades compared to low grades.

Conclusions

ETR in patients with higher grades of liver inflammation was 17% higher than those with lower grades irrespective of fibrosis and 9% higher for bridging fibrosis and cirrhosis. Pretreatment ALT was moderately accurate for severe inflammation only on liver biopsy in both males and females.

Development and validation of sunlight exposure measurement questionnaire (SEM-Q) for use in adult population residing in Pakistan

Background

Vitamin D deficiency has been identified as a major public health problem worldwide. Sunlight is the main source of vitamin D and its measurement using dosimeters is expensive and difficult for use in population-based studies. Hence, the aim of this study was to develop and validate questionnaires to assess sunlight exposure in healthy individuals residing in Karachi, Pakistan.

Methods

Two questionnaires with seven important items for sunlight exposure assessment were developed. Fifty four healthy adults were enrolled based on their reported sunlight exposure (high = 17, moderate = 18, low = 19) from Aga Khan University, Karachi. Over four days, study participants were asked to wear a dosimeter between sunrise and sunset and report time spent and activities undertaken in the sun for questionnaire validation. Algorithm for item weightage was created as an average score based on ultraviolet B percentage received. Blood samples were obtained for serum vitamin D.

Results

The mean time (minutes) spent in sun over 4 days (±SD) was 69.5 (±32) for low, 83.5 (±29.7) for moderate and 329 (±115) for high exposure group. The correlation between average time (minutes) spent in sun over 4 days and mean change in absorbance of UV dosimeters for 4 days was 0.60 (p < 0.01). Correlation between average score and vitamin D levels was found to be 0.36 (p = 0.01) for short term questionnaire score, 0.43 (p = 0.01) for long term questionnaire score in summers and 0.48 (p = 0.01) in winters.

Conclusions

The sunlight exposure measurement questionnaires were valid tools for use in large epidemiological studies to quantify sunlight exposure.

Risk of low birth weight and stillbirth associated with indoor air pollution from solid fuel use in developing countries

Exposure to indoor air pollution from solid fuel use (IAP) has been linked to approximately 1.5 million annual deaths (World Health Organization (http://www.who.int/indoorair/publications/fuelforlife/en/index.html)) due to acute lower respiratory infections in children <5 years of age and chronic obstructive lung disease and lung cancer in adults. Emerging evidence suggests that IAP increases the risk of other conditions, including adverse pregnancy outcomes. To establish the relation of IAP with birth weight and stillbirth, systematic reviews with meta-analyses were conducted. Studies reporting outcomes of mean birth weight, percentage of low birth weight (LBW; <2,500 g), and/or stillbirth and assessing IAP were identified. Five LBW studies (of 982) and 3 stillbirth studies (of 171) met inclusion criteria for the reviews. Fixed-effect meta-analyses (I(2) = 0%) found that IAP was associated with increased risk of percentage LBW (odds ratio = 1.38, 95% confidence interval: 1.25, 1.52) and stillbirth (odds ratio = 1.51, 95% confidence interval: 1.23, 1.85) and reduced mean birth weight (-95.6 g, 95% confidence interval: -68.5, -124.7). Evidence from secondhand smoke, ambient air pollution, and animal studies--and suggested plausible mechanisms--substantiate these associations. Because a majority of pregnant women in developing countries, where rates of LBW and stillbirth are high, are heavily exposed to IAP, increased relative risk translates into substantial population attributable risks of 21% (LBW) and 26% (stillbirth).

Indoor carbon monoxide and PM2.5 concentrations by cooking fuels in Pakistan

In developing countries biomass combustion is a frequently used source of domestic energy and may cause indoor air pollution. Carbon monoxide (CO)and particulate matter with an aerodynamic diameter of 2.5 lm or less (PM2.5)were measured in kitchens using wood or natural gas (NG) in a semi-rural community in Pakistan. Daytime CO and PM2.5 levels were measured for eight continuous hours in 51 wood and 44 NG users from December 2005 to April 2006. The laser photometer PM2.5 (Dustrak, TSI) was calibrated for field conditions and PM2.5 measurements were reduced by a factor of 2.77. CO was measured by an electrochemical monitor (Model T15v, Langan). The arithmetic mean for daytime CO concentration was 29.4 ppm in wood users; significantly higher than 7.5 ppm in NG users (P < 0.001). The arithmetic mean for daytime PM2.5 concentrations was 2.74 mg/m3 in wood users; significantly higher than 0.38 mg/m3 in NG users (P < 0.001). Higher peak levels of CO and PM2.5 were also observed in wood users. Time spent in the kitchen during fuel burning was significantly related to increasing CO and PM2.5 concentrations in wood users.These findings suggest that cooking with wood fuel may lead to hazardous concentrations of CO and PM2.5.

PRACTICAL IMPLICATIONS

Biomass combustion is frequently used in developing countries for cooking. This study showed very high level of air pollution in kitchens using wood as the cooking fuel. Many people, especially women and children, are vulnerable to exposure to very high levels of air pollutants as they spend time in the kitchen during cooking hours.

Does malaria during pregnancy affect the newborn?

OBJECTIVE

To investigate the effect of malarial infection during pregnancy on the newborn.

METHODS

A retrospective cohort study was conducted at The Aga Khan University Hospital (AKUH), Karachi, using in-patient hospital records over an 11-year period from 1988 to 1999. The incidence of preterm delivery, low birth weight (LBW) and intrauterine growth retardation (IUGR) in 29 pregnant women with malaria, was compared with that in 66 selected pregnant women without malaria, who delivered at the AKUH during the same time period.

RESULTS

Pregnant women with malaria had a 3.1 times greater risk of preterm labor (p=0.14). They were more likely to be anaemic compared to women without malaria (RR=2.9, 95% CI=1.6-5.4) and had a significantly lower mean haemoglobin level (p=0.0001). Maternal malaria was significantly associated with LBW babies (p=0.001). The mean birth weight of infants born to pregnant women with malaria was 461 g less (p=0.0005). No significant association was, however, found between malarial infection during pregnancy and IUGR (p=0.33).

CONCLUSION

Malarial infection during pregnancy is associated with poor maternal and fetal outcome. It is significantly associated with maternal anaemia and LBW infants. Appropriate measures must, therefore, be taken to prevent malaria during pregnancy, especially in endemic areas.

Crimean-Congo Hemorrhagic Fever: Prevention and Control Limitations in a Resource-Poor Country

In autumn 2000, an outbreak of Crimean-Congo hemorrhagic fever (CCHF) occurred in Pakistan and involved nosocomial cases due to human-to-human transmission at a tertiary care hospital in Karachi. During a hospital-based investigation, 6 serologically confirmed cases (i.e., patients seropositive for CCHF antigen or anti-CCHF immunoglobulin M antibodies by means of a capture enzyme-linked immunosorbent assay [ELISA]) and 3 clinically confirmed cases (i.e., patients with negative ELISA for CCHF but with relevant epidemiologic exposures and compatible clinical disease) of CCHF were identified. The outbreak originated in rural Balochistan, a region of known CCHF endemicity where miniepidemics regularly occur, and subsequently spread to the urban centers of Quetta and Karachi. This outbreak demonstrated the capacities and weaknesses associated with a developing country's response to hemorrhagic fever epidemics. We describe aspects of disease prevention, control challenges, and political obstacles posed by illness associated with what we refer to as the "Asian Ebola virus."

Surgical wound infection surveillance in general surgery procedures at a teaching hospital in Pakistan

BACKGROUND

A surveillance system was established at the Aga Khan University Hospital in Karachi, Pakistan, to determine surgical wound infection (SWI) rates, trends, and risk factors; and to compare rates with those reported by the National Nosocomial Infection Surveillance (NNIS) system of the Centers for Disease Control and Prevention.

METHODS

Surveillance was performed from January 1997 to December 1999. Risk categorization was on the basis of the NNIS system. P <.05 was set for statistically significant difference between groups. Data were analyzed using the Epi-Info software (version 6.04, CDC, Atlanta, Ga).

RESULTS

Overall SWI rates for the NNIS risk categories 0, 1, 2, and 3 were 1.9%, 3.7%, 6.7%, and 5.1%, respectively. SWI rate in 0 risk category decreased from 3% in 1997 to 1.1% in 1999 (P =.06). Multivariate analysis showed that SWI rates were higher after mastectomy (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.8-10), hernia repair (OR 3.28, 95% CI 1.6-6.7), gastrointestinal resection (OR 2.2, 95% CI 0.88-5.9), skin procedures (OR 1.97, 95% CI 0.89-4.3), appendectomy OR 0.57, 95% CI 0.20-1.60, and miscellaneous procedures (OR 3.6, 95% CI 1.6-7.7), as compared with cholecystectomy. Other risk factors were contaminated type of operation (OR 2.6, 95% CI 1.2-5.5), and duration of operation exceeding the NNIS standard of "T" hours (OR 2.6, 95% CI 1.7-4).

CONCLUSION

The SWI rates at the Aga Khan University Hospital are higher than the NNIS standards. There was a downward trend in the SWI rates during the surveillance period. A decrease in the duration of surgical procedures could further reduce the risk.

Melanoma patients evaluated by four different positron emission tomography reconstruction techniques

One hundred and nineteen patients with malignant melanoma were studied using 2-[ F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET). The images were reconstructed using ordered subset expectation maximization with and without attenuation correction and filtered backprojection with and without attenuation correction. The most probable draining lymph node chains were surgically explored and the tumour volume was quantified at histology. The four different reconstructions of the PET images were retrospectively graded on a five-point scale by two blind readers and compared with the tumour volume. The readers agreed within +/-1 grade 93% (529/568) of the time. Comparing the areas under the receiver operating characteristic (ROC) curves gave 0.698, 0.668, 0.694 and 0.684 for the four reconstruction techniques. The lowest value comparing any pair of the four reconstruction techniques was P=0.371. Thus, none of the reconstruction techniques gave significantly better results than any of the others. The sensitivity of detection was 85% for tumour volumes of 113 m or more (about 6 mm in diameter), but only 4% for tumours less than this size. It can be concluded that the use of attenuation correction gives aesthetically more pleasing images, but the sensitivity and specificity are not significantly improved.

Hormone replacement therapy menopause with a better future--a survey of views on hormone replacement therapy (HRT)

OBJECTIVE

To assess the views and prescribing practices of doctors regarding hormone replacement therapy (HRT).

METHODS

In April 1999, 103 doctors from a teaching hospital participated in a survey. Using a self-administered questionnaire, subjects were contacted at the departments of Internal Medicine, Family Medicine, Obstetrics and Gynaecology, and Orthopaedics.

RESULTS

Seventy-two percent were below 40 years of age and 67% of the respondents were male. Most doctors believed that HRT decreases the risk of subsequent osteoporosis (97%), ischaemic heart disease (77%) and depression associated with menopause (64%). Doctors generally considered menopausal symptoms (90%), premature menopause (87%), surgical menopause (85%) and osteoporotic fracture (77%) as clear indications for hormone replacement therapy. Absolute contraindications to the therapy were stated as recent breast cancer (82%) and recent endometrial cancer (84%). Among the specialities covered, there were differing views on proposed duration of HRT. It was generally believed that a pelvic examination, cervical smear and mammography were pre-requisites when initiating and monitoring HRT. Majority (69%) felt that HRT should be offered to all menopausal women, assuming no contraindications and most (73%) did discuss HRT with their patients. However, less than 10% of the menopausal patients under their care were using HRT. Those doctors not in favor of universal offering of HRT (31%) considered unreliable patient follow up to be the main reason. Females were two times more likely to discuss HRT with their patients (p = .08). Doctors who discussed HRT with their patients were four times more likely to consider HRT for themselves or their spouses (p = .13). Gynecologists were eight times more likely to prescribe HRT than non-gynecologists (p = .001).

CONCLUSION

Doctors are positively disposed to the universal offering, and use of HRT. Further studies are needed to understand a possible gap between perceived and actual prescribing practice.

The value of good medical student teaching: increasing the number of radiology residency applicants

RATIONALE AND OBJECTIVES

The authors attempted to define the value of good medical student teaching to the profession of radiology by examining the effect of radiology course improvements on the number of 4th-year students applying to radiology residencies.

MATERIALS AND METHODS

Course evaluation and residency application data were obtained from six consecutive classes of 4th-year medical students at the study institution, and these data were compared with national data.

RESULTS

Between 1995 and 2000, the number of 4th-year U.S. medical students applying to radiology increased 1.6 times. At the study institution, that number increased 4.5 times, a statistically significant difference (P = .020, chi2 test). Student survey data indicate that this increase reflects a general increase in the quality of radiology teaching in the study institution and specific changes in a required 2nd-year medical school course.

CONCLUSION

These results strongly suggest that good medical student teaching pays important dividends, not only to the departments that provide it but also to the profession of radiology as a whole. Exposing students to good radiology teaching early in their medical school careers is especially important. Radiology departments that provide outstanding medical student education should be studied to help develop a model of educational best practices.

Paan without tobacco: an independent risk factor for oral cancer

Oral cancer is the second most common cancer in women and the third most common in men in Pakistan. Tobacco is smoked and chewed extensively in Pakistan. Paan is a quid of piper betel leaf that contains areca nut, lime, condiment, sweeteners, and sometimes tobacco, which is also used extensively. We did this study to clarify the independent association of paan and oral cancer. Between July 1996 and March 1998, we recruited biopsy-proven, primary cases of oral squamous-cell carcinoma, from 3 tertiary teaching centers in Karachi, Pakistan, and controls pair-matched for age, gender, hospital and time of occurrence, excluding persons with a past or present history of any malignancy. There were 79 cases and 149 controls. Approximately 68% of the cases were men, 49 years old on average, the youngest being 22 years old and the eldest 80. People with oral submucous fibrosis were 19.1 times more likely to develop oral cancer than those without it, after adjusting for other risk factors. People using paan without tobacco were 9.9 times, those using paan with tobacco 8.4 times, more likely to develop oral cancer as compared with non-users, after adjustment for other covariates. This study identifies an independent effect of paan without tobacco in the causation of oral cancer. Its findings may be of significance in South Asian communities where paan is used, and among health-care providers who treat persons from South Asia.

Clinical applications of technetium Tc 99m hexamethyl propylene amine oxime leukocyte scan in children with inflammatory bowel disease

BACKGROUND

Labeled leukocyte imaging is a helpful diagnostic tool in the detection of inflammation and sepsis. The technetium Tc 99m hexamethyl propylene amine oxime (99mTc HMPAO)-labeled leukocyte scan has been found to be more sensitive than the Indium-111 labeled leukocyte scan in detecting inflammatory bowel disease, with reported sensitivities of 95% to 100%. Experience with the 99mTc HMPAO-labeled leukocyte scan was examined and its clinical applications evaluated in the immediate treatment of patients with inflammatory bowel disease.

METHODS

A retrospective chart review was undertaken that included pediatric patients who underwent 99mTc HMPAO-labeled leukocyte scan at the James Whitcomb Riley Hospital for Children. The disease activity of patients with inflammatory bowel disease was assessed. The leukocyte scan was performed according to the manufacturer's specifications, and images were obtained 30 minutes and 2 hours after administration of the radiopharmaceutical.

RESULTS

During the period of July 1996 through November 1997, 41 scans were performed in 35 patients. Twenty-nine patients had histologically proven inflammatory bowel disease: 24 with Crohn's disease, 4 with ulcerative colitis, and 1 with indeterminate colitis. Active inflammatory bowel disease was suspected in 24 patients when the leukocyte scan was performed. Twenty of the 24 patients (83% sensitivity) had abnormal findings in leukocyte scans that prompted more aggressive management in 15 (75%). Six of the 15 who were receiving maximum medical therapy underwent surgical resection of severely affected bowel segments, and medical treatment was intensified in the other 9. The remaining 5 patients were receiving optimal medical therapy, instituted at their recent visit, and did not require further medication adjustments. Four of the 24 patients with active inflammatory bowel disease had normal leukocyte scans (17% false-negative rate), 3 of whom were receiving corticosteroid therapy at the time the scans were performed. All of the 11 patients in whom inflammatory bowel disease was in remission and 6 patients who did not have inflammatory bowel disease had normal findings in leukocyte scans (100% specificity).

CONCLUSIONS

Although a tissue diagnosis is still recommended, obtained during upper and lower gastrointestinal endoscopic examinations, and contrast radiography of the small bowel for the initial work-up of patients with suspected inflammatory bowel disease, the 99mTc HMPAO-labeled leukocyte scan is a safe and useful diagnostic adjunct for subsequent evaluation of patients known to have inflammatory bowel disease. The results of 99mTc HMPAO-labeled leukocyte scans directly influenced treatment of 75% of the study patients with active inflammatory bowel disease, which included the decision to refer patients for surgical intervention.

A short echo 1H spectroscopy and volumetric MRI study of the corpus striatum in patients with obsessive-compulsive disorder and comparison subjects

OBJECTIVE

It is likely that the corpus striatum is involved in obsessive-compulsive disorder (OCD). Prior studies have inconsistently found alterations in caudate volumes in patients with OCD. This study was undertaken in the hope that N-acetylaspartate and volumetric measures together would elucidate the presence and nature of corpus striatum volumetric abnormalities in OCD.

METHOD

Thirteen patients meeting the DSM-IV criteria for OCD, who had been medication free for a minimum of 6 weeks, and 13 psychiatrically normal matched comparison subjects participated in the study. Short echo 1H magnetic resonance spectroscopy (1H-MRS) was used to measure levels of N-acetylaspartate and several other cerebral metabolites from a 4.5-cm3 volume in the left corpus striatum of all 26 subjects. Metabolite levels were estimated by fitting the time domain spectroscopy data with a noninteractive computer program. Volumes of the left and right head of the caudate nucleus in each subject were determined by semiautomatic segmentation of the volumetric images.

RESULTS

N-Acetylaspartate levels from the left corpus striatum were significantly lower in the patients with OCD than in the comparison subjects. There were no differences in either left or right caudate volume between the two groups.

CONCLUSIONS

Despite the lack of differences in caudate volumes between the OCD patients and the comparison subjects, the lower level of N-acetylaspartate in the left corpus striatum of the patients suggests reduced neuronal density in this region. Inconsistent volumetric findings among prior studies may reflect a poorer sensitivity of magnetic resonance imaging morphometry for detecting neuronal loss compared with 1H-MRS measurement of N-acetylaspartate.

High rates of discitis following surgery for prolapsed intervertebral discs at a hospital in Pakistan

OBJECTIVES

To confirm the presence of an outbreak of postoperative infections following laminectomy and to determine the infection rate after interventions were instituted.

DESIGN

Retrospective cohort study. Medical records were reviewed, personnel interviewed, and premises examined.

SETTING

Surgical unit of hospital A in Pakistan.

SUBJECTS

Patients who had surgical laminectomy between January 1993 and July 1994.

INTERVENTION

Instructive program for nursing and medical staff in December 1993.

RESULTS

From January to December 1993, 6 (15%) of 41 laminectomy patients developed postoperative discitis. The risk of discitis varied significantly by surgeon (P = .016); patients who had one particular surgeon, surgeon A, were nine times more likely to develop postoperative infections than patients who did not have surgeon A. Patients were not consistently cleaned or shaved before coming to the operating room, and personnel moved back and forth between the operation theater and other parts of the hospital without changing their gowns or slippers. After the instructional intervention, between January and July 1994, 2 (6%) of 31 laminectomy patients developed postoperative discitis, a rate not significantly lower than in the preceding 12 months (P = .45). Overall, from January 1993 through July 1994, female patients were more likely to develop discitis than males (31% vs 7%; relative risk, 4.4; 95% confidence interval, 1.3-15.6; P < .032).

CONCLUSION

Endemic conditions require that laminectomy at hospital A be limited to those situations where the benefits of the surgery exceed the considerable risk of postoperative discitis.

Contamination of the pleural surfaces in childhood sarcoma. Use of colloidal P-32 to reduce radiation dose to the whole lung

Children with pulmonary sarcomas who have diffuse contamination of the pleural cavity present a difficult management problem for the radiation oncologist. Doses required to control even microscopic disease exceed lung tolerance. We report on the use of intracavity colloid P-32 in an attempt to treat the pleural surface and spare normal lung parenchyma and tissues of the chest wall. Three children--18 months, 12 years, and 3 years of age--had spillage of pulmonary sarcomas into the chest cavity. All children were treated with systemic chemotherapy. Initially, 0.5 mCi of technetium sulfur colloid (99mTc-sulfur colloid) was instilled into the pleural space to ascertain even distribution of isotope. This was then followed by installation of 5.0 mCi of colloidal P-32. Uniform distribution was then confirmed by bremsstrahlung scanning. All three patients are in complete remission 3.5 years, 3 years, and 1 year after treatment, respectively. The major toxicity was asymptomatic pleural thickening, which could be confused with disease. This was confirmed histologically to be fibrous in the first patient. The process diminished or stabilized with time in all 3 patients over the period of observation. In this small series, intrapleural colloidal P-32 appeared to be safe and well tolerated and would be expected to be less toxic than wide-field external beam in the treatment of spilled pulmonary sarcomas.

Imaging modalities in pediatric oncology

Many imaging modalities are available for the diagnosis, follow-up, and sometimes treatment of pediatric oncology diseases. The advantages and disadvantages, indications and contraindications, techniques, and patient preparations of the most commonly used modalities are discussed in this article. The role of sedation and the most widely used drugs are also discussed.

Visual presentation of the staging of pediatric solid tumors

Staging systems are used in staging most pediatric solid tumors outside the central nervous system. Common solid, nonneurologic pediatric tumors include liver tumors, Hodgkin disease, non-Hodgkin lymphoma, Wilms tumor, rhabdomyosarcoma, neuroblastoma, Ewing sarcoma, and osteosarcoma. Traditional staging of pediatric tumors depends on the anatomic distribution of the malignant disease. Almost all staging systems are based on the spread of the local primary tumor, metastasis to regional lymph nodes, and distant blood-borne metastatic spread. There is some variability as to how tumor spread is assessed. Such assessment may be performed before or after surgery. There are many potential problems with tumor staging systems. The systems vary in complexity and clinical usefulness, and there is some variation in the criteria used in the different systems. It is important for radiologists to have a sound working knowledge of staging systems to facilitate accurate staging. Imaging is an important aspect of every staging system.

Quantification of intrahepatic portosystemic shunting after placement of a transjugular intrahepatic portosystemic shunt

PURPOSE

To quantify portosystemic shunting and hepatic portal perfusion after placement of a transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Technetium-99m macroaggregated albumin (MAA) was injected directly into the portal veins of nine asymptomatic patients 3 months after TIPS placement. Portosystemic shunting was quantified by comparing counts in the lungs with those in the liver. One cirrhotic patient and one healthy patient who received portal MAA injections were used as controls.

RESULTS

No portosystemic shunting was found in the healthy patient. In the cirrhotic control patient, 77% of the injected activity was in the lungs. Patients with portosystemic shunts had even more activity in the lungs. Even stenotic shunts diverted greater than 80% of portal blood flow systemically. Flow through the TIPS ranged from 84% to 100% (average, 93%); these fractions of flow correlated inversely with portosystemic pressure gradients.

CONCLUSION

Cirrhotic livers may divert much of the portal blood systemically before TIPS placement. Afterward, this proportion rises, and most portal flow is diverted into the pulmonary circulation.

Hürthle cell carcinoma in an autonomous thyroid nodule in an adolescent

A 16-year-old girl presented with a palpable thyroid nodule which was found to be functioning autonomously by radioiodine (123I) scintigraphy. After needle biopsy proved non-diagnostic, surgical excision showed the nodule to be Hürthle cell carcinoma. Functional thyroid nodules are rarely malignant, thyroid carcinoma is rare in childhood, and Hürthle cell carcinoma is a rare thyroid neoplasm, so the presence of these three rare conditions in one patient makes it a very unusual case.

Osteomyelitis and pyogenic infection of the sacroiliac joint. MRI findings and review

Acute pyogenic sacroiliac joint infection and osteomyelitis of adjacent bones often present with severe, poorly localized lower back, pelvic or hip pain. Five cases of sacroiliac joint infection or sacroiliac bone osteomyelitis were evaluated by MRI. MRI may be a helpful diagnostic tool to evaluate early changes of infection in the sacroiliac area. It is very sensitive for detecting bone marrow abnormalities; however, it is non-specific and can not accurately differentiate osteomyelitis from sacroiliitis.

Prospective study of magnetic resonance imaging and SPECT bone scans in renal allograft recipients: evidence for a self-limited subclinical abnormality of the hip

We recently reported that typical abnormalities of avascular necrosis (AVN) in magnetic resonance images (MRI) of the hips of asymptomatic renal transplant recipients whose plain radiographs are normal may improve spontaneously and even disappear completely. We present the results of serial bone scans, most of which were performed with single-photon emission computed tomography obtained over periods as long as 24 mo after transplantation in 72 of these patients. Three paired imaging studies (i.e., MR and bone scan performed within 30 days of each other) were available for each of these patients. In three patients, both the MR images and the bone scans showed changes consistent with bilateral AVN within 4 mo after transplantation. All three patients developed hip pain which was bilateral in two and unilateral in one. Two patients (three hips) required surgical intervention at which time AVN was found on pathologic examination of all three hips. None of the remaining 69 patients developed hip pain during the study. However, in nine patients whose MR studies were consistently normal, at least one bone scan was abnormal (13 hips). The presence of AVN was pathologically confirmed in each of the hips subjected to surgery. Where the imaging findings were identical to those in the asymptomatic patients as well as those in whom the imaging abnormality regressed, we suggest that the subclinical imaging abnormalities represent mild AVN, which is reversible in some cases. Since the process was identified in 10 hips by MRI and in 13 hips by bone scan, both studies are needed to detect subclinical AVN. This may be important if treatment of subclinical disease is clearly shown to prevent progression to symptomatic AVN.

Isotope studies in children: an update

Hepatobiliary scintigraphy is an accurate, simple, and relatively noninvasive method for the diagnosis of biliary atresia, a condition in which early diagnosis is of paramount importance. Radionuclide gastrointestinal transit studies are useful in devising the surgical approach in children with suspected gastroesophageal reflux. Renal scintigraphy in the newborn period is used to decide the need for surgical intervention in a hydronephrotic kidney. Relatively new radiopharmaceuticals such as metaiodobenzyleguanidine, thallium, and deoxyglucose are useful in detecting tumors and in predicting the viability.

HIPDM-SPECT brain imaging in the presurgical evaluation of patients with intractable seizures

We report the results of interictal and ictal HIPDM-SPECT brain imaging in 34 patients who eventually underwent temporal lobectomy for treatment of medically intractable complex partial seizures. Interictal studies revealed decreased regional cerebral perfusion (rCP) in the temporal lobe corresponding to the eventual site of surgery in 73% of the patients. Similarly, ictal study demonstrated increased rCP in 93% of the patients. In 69% of the patients, the SPECT studies were able to demonstrate both increased rCP on the ictal scan and decreased rCP on the interictal scan in the same location, corresponding to the eventual site of surgery. These results suggest that interictal and ictal SPECT brain imaging can be easily obtained and provide reliable localizing information in the presurgical evaluation of patients with medically intractable epilepsy.