PNEUMONIA IN CHILDREN LIVING AT HIGH ALTITUDES IN PAKISTAN

Pneumonia is responsible for an estimated 44% of deaths in children under 5 years of age in the Himalayan communities of the Northern Areas, Pakistan. The objectives of the three papers included in this thesis were to 1) determine the incidence of pneumonia in children using the World Health Organization Integrated Management of Childhood Illness (IMCI) criteria; 2) evaluate the impact of intensive follow-up training for Community Health Workers (CHWs) on pneumonia recognition and referral; and 3) compare health center staff classification of pneumonia based on IMCI criteria with evaluation by pediatricians. Children 2-35 months were followed at home every two weeks by CHWs and surveillance was simultaneously established at 15 health centers for pneumonia. CHW performance was evaluated at six-weekly intervals using pre- and post-tests, by measuring the proportion of children with severe disease they referred correctly to health centers, and by comparing the incidence rates for pneumonia among children in their coverage area. Misclassification of disease was measured by determining overall agreement between health center staff classification of disease with a pediatrician’s evaluation at a referral hospital in Gilgit. The incidence rate was 29.9 per 100 child years of observation (CYO) for pneumonia and 8.1 per 100 CYO for severe pneumonia. The proportion of children that were correctly referred for severe disease by CHWs increased from zero at baseline to above 80% over one year. Significant improvements were reported between the pre- and post-test results of CHW in all 10 tests conducted (paired sample t-test p-value <0.001). Using the pediatrician’s diagnosis as reference, health center staff correctly classified 125 (74.9%) of the children with severe pneumonia, and failed to identify 42 (25.1%) of children with the disease. Staff incorrectly labeled 328 (72.4%) children from the 453 they classified as children with severe pneumonia. Fewer children with pneumonia were missed (11.5%) or labeled incorrectly (2.8%). The pneumonia incidence rates in this Himalayan region are among the highest reported, even after adjustments for over-diagnosis of severe pneumonia. Sustained improvements in pneumonia referral were achieved following intensive training for CHWs. These findings warrant consideration of new intervention strategies in this region

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report

Importance: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine.Case presentation: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay.Clinical discussion: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations.Conclusion: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium

The cost-effectiveness of incentive-based active case finding for tuberculosis (TB) control in the private sector Karachi, Pakistan

Background: In Asia, over 50% of patients with symptoms of tuberculosis (TB) access health care from private providers. These patients are usually not notified to the National TB Control Programs, which contributes to low notification rates in many countries. Methods: From January 1, 2011 to December 31, 2012, Karachi’s Indus Hospital - a private sector partner to the National TB Programme - engaged 80 private family clinics in its catchment area in active case finding using health worker incentives to increase notification of TB disease. The costs incurred were estimated from the perspective of patients, health facility and the program providing TB services. A Markov decision tree model was developed to calculate the cost-effectiveness of the active case finding as compared to case detection through the routine passive TB centers. Pakistan has a large private health sector, which can be mobilized for TB screening using an incentivized active case finding strategy. Currently, TB screening is largely performed in specialist public TB centers through passive case finding. Active and passive case finding strategies are assumed to operate independently from each other. Results: The incentive-based active case finding program costed USD 223 per patient treated. In contrast, the center based non-incentive arm was 23.4% cheaper, costing USD 171 per patient treated. Cost-effectiveness analysis showed that the incentive-based active case finding program was more effective and less expensive per DALY averted when compared to the baseline passive case finding as it averts an additional 0.01966 DALYs and saved 15.74 US$ per patient treated. Conclusion: Both screening strategies appear to be cost-effective in an urban Pakistan context. Incentive driven active case findings of TB in the private sector costs less and averts more DALYs per health seeker than passive case finding, when both alternatives are compared to a common baseline situation of no screening.publishedVersio

Morphological and molecular characterization of Oyster mushroom (Pleurotus spp.)

Mushrooms have medicinal as well as nutritive value and extensively used as human food from the time immortal. In order to determine the genetic diversity among Pleurotus species of mushroom using morphological and random amplified polymorphic DNA (RAPD) markers, about seven different species were collected. Five species, naming Pleurotus platypus (P-6), Pleurotus flabelatus (P-7), Pleurotus florida (P-17), Pleurotus ostreatus (P-19) and Pleurotus sajor-caju (P-56) were from Canada and two Pleurotus warm-stram (P-9) and Pleurotus eryngii (P-16) from Philpines. Seven different morphological traits that is, mycelial growth (mm), cap diameter (cm), total yield (kg), moisture contents (%), ash contents (%), nitrogen contents (%) and protein content (%) were recorded. The dendrogram based on morphological data divided seven species in cluster ‘A’ and ‘B’ having four and three species, respectively. The dendrogram based on RAPD analysis generated 3 clusters ‘A’, ‘B’ and ‘C’. Out of 14 random primers, the maximum polymorphism was observed by primers OPL3 (72.70 %) and OPL11 (70%). The two species P-56 and P-17 were observed to be most similar having value 86% and constituting a cluster ‘A’. The present work revealed that, morphological and RAPD markers showed different pattern of genetic diversity among different Pleurotus species.Keywords: Oyster mushrooms, genetic diversity, random amplified polymorphic DNA (RAPD) markers, dendrogra

Geographic variation in access to dog-bite care in Pakistan and risk of dog-bite exposure in Karachi: prospective surveillance using a low-cost mobile phone system

Background: Dog-bites and rabies are under-reported in developing countries such as Pakistan and there is a poor understanding of the disease burden. We prospectively collected data utilizing mobile phones for dog-bite and rabies surveillance across nine emergency rooms (ER) in Pakistan, recording patient health-seeking behaviors, access to care and analyzed spatial distribution of cases from Karachi. Methodology and Principal: Findings A total of 6212 dog-bite cases were identified over two years starting in February 2009 with largest number reported from Karachi (59.7%), followed by Peshawar (13.1%) and Hyderabad (11.4%). Severity of dog-bites was assessed using the WHO classification. Forty percent of patients had Category I (least severe) bites, 28.1% had Category II bites and 31.9% had Category III (most severe bites). Patients visiting a large public hospital ER in Karachi were least likely to seek immediate healthcare at non-medical facilities (Odds Ratio = 0.20, 95% CI 0.17–0.23, p-value<0.01), and had shorter mean travel time to emergency rooms, adjusted for age and gender (32.78 min, 95% CI 31.82–33.78, p-value<0.01) than patients visiting hospitals in smaller cities. Spatial analysis of dog-bites in Karachi suggested clustering of cases (Moran's I = 0.02, p value<0.01), and increased risk of exposure in particular around Korangi and Malir that are adjacent to the city's largest abattoir in Landhi. The direct cost of operating the mHealth surveillance system was USD 7.15 per dog-bite case reported, or approximately USD 44,408 over two years. Conclusions: Our findings suggest significant differences in access to care and health-seeking behaviors in Pakistan following dog-bites. The distribution of cases in Karachi was suggestive of clustering of cases that could guide targeted disease-control efforts in the city. Mobile phone technologies for health (mHealth) allowed for the operation of a national-level disease reporting and surveillance system at a low cost.publishedVersio

Bismuth-Doped Nano Zerovalent Iron: A Novel Catalyst for Chloramphenicol Degradation and Hydrogen Production

© In this study, we showed that doping bismuth (Bi) at the surface of Fe0 (Bi/Fe0, bimetallic iron system) - synthesized by a simple borohydride reduction method - can considerably accelerate the reductive degradation of chloramphenicol (CHP). At a reaction time of 12 min, 62, 68, 74, 95, and 82% degradation of CHP was achieved with Fe0, Bi/Fe0-1 [1% (w/w) of Bi], Bi/Fe0-3 [3% (w/w) of Bi], Bi/Fe0-5 [5% (w/w) of Bi], and Bi/Fe0-8 [8% (w/w) of Bi], respectively. Further improvements in the degradation efficiency of CHP were observed by combining the peroxymonosulfate (HSO5-) with Bi/Fe0-5 (i.e., 81% by Bi/Fe0-5 and 98% by the Bi/Fe0-5/HSO5- system at 8 min of treatment). Interestingly, both Fe0 and Bi/Fe0-5 showed effective H2 production under dark conditions that reached 544 and 712 μM by Fe0 and Bi/Fe0-5, respectively, in 70 mL of aqueous solution containing 0.07 g (i.e., at 1 g L-1 concentration) of the catalyst at ambient temperature

Transport time to trauma facilities in Karachi: an exploratory study

Background: Rapid urban growth in developing countries has outpaced the development of health infrastructure, including trauma centers, leading to potential delays in trauma care. This study was conducted in Karachi, a city of 16 million people in Pakistan. Aims: Our aim was to determine the time taken to reach the nearest 24-h emergency care facility (ECF) and the government-designated trauma center (TC). We also sought to determine the availability of supplies and equipment required for basic trauma care at these centers.Methods:We selected five towns in Karachi that had the highest number of road traffic injuries (RTIs) (as identified through medicolegal records). We then measured the time taken to reach the nearest ECF and the government-designated TC from four compass points within each town. We also asked about the equipment and supplies used in basic trauma care.Results: All three TCs in Karachi were located in the selected towns and were within 5.0-10.5 km of each other. The transport times to the 3 TCs were an average of 13.3 min (+/- 7.1) and to the 16 ECFs an average of 4.7 min (+/- 2.4) (p value \u3c 0.00). Most ECFs did not have all equipment and supplies necessary for basic trauma care, 90% had the basic equipment for management of airway, oxygen, and IV fluids, 70% had morphine, and 45% had C-spine collars. Conclusions: Vital time is lost in reaching a government-designated TC. ECFs might be an alternative option, but are not fully equipped and funded to provide adequate trauma care to all

Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan – patient characteristics and predictors of in-hospital mortality

BACKGROUND: Intra-aortic balloon counterpulsation (IABC) has an established role in the treatment of patients presenting with critical cardiac illnesses, including cardiogenic shock, refractory ischemia and for prophylaxis and treatment of complications of percutaneous coronary interventions (PCI). Patients requiring IABC represent a high-risk subset with an expected high mortality. There are virtually no data on usage patterns as well as outcomes of patients in the Indo-Pakistan subcontinent who require IABC. This is the first report on a sizeable experience with IABC from Pakistan. METHODS: Hospital charts of 95 patients (mean age 58.8 (± 10.4) years; 78.9% male) undergoing IABC between 2000–2002 were reviewed. Logistic regression was used to determine univariate and multivariate predictors of in-hospital mortality. RESULTS: The most frequent indications for IABC were cardiogenic shock (48.4%) and refractory ischemia (24.2%). Revascularization (surgical or PCI) was performed in 74 patients (77.9%). The overall in-hospital mortality rate was 34.7%. Univariate predictors of in-hospital mortality included (odds ratio [95% CI]) age (OR 1.06 [1.01–1.11] for every year increase in age); diabetes (OR 3.68 [1.51–8.92]) and cardiogenic shock at presentation (OR 4.85 [1.92–12.2]). Furthermore, prior CABG (OR 0.12 [0.04–0.34]), and in-hospital revascularization (OR 0.05 [0.01–0.189]) was protective against mortality. In the multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.13 [1.05–1.22] for every year increase in age); diabetes (OR 6.35 [1.61–24.97]) and cardiogenic shock at presentation (OR 10.0 [2.33–42.95]). Again, revascularization during hospitalization (OR 0.02 [0.003–0.12]) conferred a protective effect. The overall complication rate was low (8.5%). CONCLUSIONS: Patients requiring IABC represent a high-risk group with substantial in-hospital mortality. Despite this high mortality, over two-thirds of patients do leave the hospital alive, suggesting that IABC is a feasible therapeutic device, even in a developing country

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

PNEUMONIA IN CHILDREN LIVING AT HIGH ALTITUDES IN PAKISTAN

Pneumonia is responsible for an estimated 44% of deaths in children under 5 years of age in the Himalayan communities of the Northern Areas, Pakistan. The objectives of the three papers included in this thesis were to 1) determine the incidence of pneumonia in children using the World Health Organization Integrated Management of Childhood Illness (IMCI) criteria; 2) evaluate the impact of intensive follow-up training for Community Health Workers (CHWs) on pneumonia recognition and referral; and 3) compare health center staff classification of pneumonia based on IMCI criteria with evaluation by pediatricians. Children 2-35 months were followed at home every two weeks by CHWs and surveillance was simultaneously established at 15 health centers for pneumonia. CHW performance was evaluated at six-weekly intervals using pre- and post-tests, by measuring the proportion of children with severe disease they referred correctly to health centers, and by comparing the incidence rates for pneumonia among children in their coverage area. Misclassification of disease was measured by determining overall agreement between health center staff classification of disease with a pediatrician’s evaluation at a referral hospital in Gilgit. The incidence rate was 29.9 per 100 child years of observation (CYO) for pneumonia and 8.1 per 100 CYO for severe pneumonia. The proportion of children that were correctly referred for severe disease by CHWs increased from zero at baseline to above 80% over one year. Significant improvements were reported between the pre- and post-test results of CHW in all 10 tests conducted (paired sample t-test p-value <0.001). Using the pediatrician’s diagnosis as reference, health center staff correctly classified 125 (74.9%) of the children with severe pneumonia, and failed to identify 42 (25.1%) of children with the disease. Staff incorrectly labeled 328 (72.4%) children from the 453 they classified as children with severe pneumonia. Fewer children with pneumonia were missed (11.5%) or labeled incorrectly (2.8%). The pneumonia incidence rates in this Himalayan region are among the highest reported, even after adjustments for over-diagnosis of severe pneumonia. Sustained improvements in pneumonia referral were achieved following intensive training for CHWs. These findings warrant consideration of new intervention strategies in this region