Acute symptomatic seizures in critically ill children: Frequency, etiology and outcomes

Background: Critically ill individuals have an increased risk of acute symptomatic seizures secondary to systemic illnesses; unrecognized or untreated seizures can quickly convert into status epilepticus, which is associated with high morbidity and mortality.Objective: The aim of this study was to determine frequency, etiology, and outcome of seizures in critical ill children admitted in intensive care unit of a tertiary care hospital.Materials and methods: Retrospective review of medical records of all children admitted in pediatric intensive care unit (PICU) of the Aga Khan University from January 2016 to December 2018 and who had a new-onset seizure irrespective of underlying diagnosis was carried out after ethical review committee approval. Data were collected on a structured proforma; it included demographic information as well as relevant clinical and outcome information. The data were analyzed on Statistical Package for the Social Sciences (SPSS) software program, version 19.0. The descriptive statistics frequency and percentage was computed for qualitative variable. Mean and standard deviation were computed for quantitative variable, and univariate analysis was performed.Results: During the study period, a total 2053 patients were admitted in the PICU. One hundred six (5%) had seizure. Sixty-three (59.5%) were males. Meningitis 21 (20%), sepsis 21 (20%), complicated pneumonia 18 (17%) were the major primary diagnosis in these children. Mean age of the study population was 75 months (standard deviation [SD] ± 54.4) and 72 (68%) were age, whereas 63 (59.5%) were males. The seizures lasted \u3e10min in 10 (10%) and were associated with high had neurological deficit (P = 0.001). We did not observe any correlation with electrolyte imbalance, renal failure, need of ventilator support with duration of seizure, and type of seizure (P \u3e 0.005).Conclusion: Infection was the most common etiology associated with a new-onset seizure in children admitted in our PICU. Seizures lasting for \u3e10min were observed with high neurological deficit. We did not find any association of mortality with seizure duration

A study protocol : using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan

Background: High fertility rates, unwanted pregnancies, low modern contraceptive prevalence and a huge unmet need for contraception adversely affect women's health in Pakistan and this problem is compounded by limited access to reliable information and quality services regarding birth spacing especially in rural and underserved areas. This paper presents a study protocol that describes an evaluation of a demand-side financing (DSF) voucher approach which aims to increase the uptake of modern contraception among women of the lowest two wealth quintiles in Punjab Province, Pakistan. Methods/Design: This study will use quasi-experimental design with control arm and be implemented in: six government clinics from the Population Welfare Department; 24 social franchise facilities branded as `Suraj' (Sun), led by Marie Stopes Society (a local non-governmental organization); and 12 private sector clinics in Chakwal, Mianwali and Bhakkar districts. The study respondents will be interviewed at baseline and endline subject to voluntary acceptance and medical eligibility. In addition, health service data will record each client visit during the study period. Discussion: The study will examine the impact of vouchers in terms of increasing the uptake of modern contraception by engaging private and public sector service providers (mid-level and medical doctors). If found effective, this approach can be a viable solution to satisfying the current demand and meeting the unmet need for contraception, particularly among the poorest socio-economic group

Comparing effectiveness of two client follow-up approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) among the underserved in rural Punjab, Pakistan : a study protocol and participants' profile

Background: Pakistan observes a very high i.e. 37 percent modern contraceptive method related discontinuation rates within 12 months of their initiation. And almost 10 percent of these episodes of discontinuation happened due to the side effects or health concerns experienced by the women. Most importantly, it was noted that more than 12,000 first-level care facilities are located in the rural areas, including rural health centers, basic health units, and family welfare centers, but more than 30% of these facilities are nonfunctional. This paper presents a study protocol and participants' profiling of a prospective cohort follow-up to compare the effectiveness of household based and telephonic approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) whilst to facilitate lowering method related discontinuation and increasing switching amongst the contraceptive users. Methods: A 12-month multi-centre, non-inferiority prospective user follow-up is employed using three different study categories: a) household based follow-up; b) telephonic follow-up; and c) passive or need-based follow-up along with the hypothetical assumption that the telephonic client follow-up is not inferior to the household based follow-up by continuation rate of LARC and the telephonic follow-up is less-costly than the household based client follow-up. This follow-up will be conducted in 22 health facilities -(16 rural and 6 urban based facilities) in district Chakwal. The first two study categories will receive scheduled but different follow-up from the field workers at 1, 3, 6, 9, and 12 month while the third one i.e. the 'passive or need-based follow-up' will serve as a control group. Using sampling software PASS 11, it was estimated to have 414 clients in each study category and around 1366 clients will be recruited to account for 10% attrition rate. Discussion: The study will help us to examine a more convenient method of effective follow-up for managing side effects, decreasing method discontinuation and increasing switching amongst users. The study information will also facilitate to develop a robust, effective and efficient mechanism for client follow-up to promote the continuation rates of LARC methods. The follow-up results and lessons learnt will be widely shared with stakeholders for their implementation and streamlining in health system

Globalization and Diversification of Interior Decoration Styles and Their Impact on Pakistani Handicrafts

With the gradual advancement of globalization, cultural values and traditional decorative practices as well as people’s lifestyles have changed through digital awareness. This has seriously affected the interior decoration industry and brought challenges to the local handicraft industry. Pakistan’s traditional handicraft is famous in the world, but the flow of imported machine-made products in Pakistan has led to a decline of Pakistan’s handicraft industry. This research investigated which factors are involved in home decoration and to see if these factors are advantageous for the handicraft industry or not. The use of handicraft decoration objects varies among people when they design their houses. Thus, study conducted a survey, which found several factors that Pakistani people emphasize in relation to home decoration. Currently, these factors do not benefit the handicraft industry as people pursue a modern lifestyle and they consider handicraft objects without innovation and design outdated. Interior decoration is seen as a major aspect of traditional Pakistani life and culture, with distinct cultural characteristics. Inspired by the latest way of thinking, an interior design first exists as a concept and is then realized through careful planning. It is meant to evoke a specific mood through the strategic use of color, space, and style. In Pakistan, home accessories are generally and strongly influenced by the current fashion in the end market, with many changes brought about by consumers’ purchasing patterns, designers’ and decorators’ styles, and economic conditions. Keeping up with constantly changing trends is the main challenge faced by the traditional handicraft industry sector. In many cases, craftspeople are disconnected from the end market, which is a challenge for them to be able to profit from their work

Globalization and Diversification of Interior Decoration Styles and Their Impact on Pakistani Handicrafts

With the gradual advancement of globalization, cultural values and traditional decorative practices as well as people’s lifestyles have changed through digital awareness. This has seriously affected the interior decoration industry and brought challenges to the local handicraft industry. Pakistan’s traditional handicraft is famous in the world, but the flow of imported machine-made products in Pakistan has led to a decline of Pakistan’s handicraft industry. This research investigated which factors are involved in home decoration and to see if these factors are advantageous for the handicraft industry or not. The use of handicraft decoration objects varies among people when they design their houses. Thus, study conducted a survey, which found several factors that Pakistani people emphasize in relation to home decoration. Currently, these factors do not benefit the handicraft industry as people pursue a modern lifestyle and they consider handicraft objects without innovation and design outdated. Interior decoration is seen as a major aspect of traditional Pakistani life and culture, with distinct cultural characteristics. Inspired by the latest way of thinking, an interior design first exists as a concept and is then realized through careful planning. It is meant to evoke a specific mood through the strategic use of color, space, and style. In Pakistan, home accessories are generally and strongly influenced by the current fashion in the end market, with many changes brought about by consumers’ purchasing patterns, designers’ and decorators’ styles, and economic conditions. Keeping up with constantly changing trends is the main challenge faced by the traditional handicraft industry sector. In many cases, craftspeople are disconnected from the end market, which is a challenge for them to be able to profit from their work

Comparing effectiveness of two client follow-up approaches in sustaining the use of long acting reversible contraceptives (LARC) among the underserved in rural Punjab, Pakistan: A study protocol and participants\u27 profile

Background: Pakistan observes a very high i.e. 37 percent modern contraceptive method related discontinuation rates within 12 months of their initiation. And almost 10 percent of these episodes of discontinuation happened due to the side effects or health concerns experienced by the women. Most importantly, it was noted that more than 12,000 first-level care facilities are located in the rural areas, including rural health centers, basic health units, and family welfare centers, but more than 30% of these facilities are nonfunctional. This paper presents a study protocol and participants\u27 profiling of a prospective cohort follow-up to compare the effectiveness of household based and telephonic approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) whilst to facilitate lowering method related discontinuation and increasing switching amongst the contraceptive users.Methods: A 12-month multi-centre, non-inferiority prospective user follow-up is employed using three different study categories: a) household based follow-up; b) telephonic follow-up; and c) passive or need-based follow-up along with the hypothetical assumption that the telephonic client follow-up is not inferior to the household based follow-up by continuation rate of LARC and the telephonic follow-up is less-costly than the household based client follow-up. This follow-up will be conducted in 22 health facilities - (16 rural and 6 urban based facilities) in district Chakwal. The first two study categories will receive scheduled but different follow-up from the field workers at 1, 3, 6, 9, and 12 month while the third one i.e. the \u27passive or need-based follow-up\u27 will serve as a control group. Using sampling software PASS 11, it was estimated to have 414 clients in each study category and around 1366 clients will be recruited to account for 10% attrition rate.Discussion: The study will help us to examine a more convenient method of effective follow-up for managing side effects, decreasing method discontinuation and increasing switching amongst users. The study information will also facilitate to develop a robust, effective and efficient mechanism for client follow-up to promote the continuation rates of LARC methods. The follow-up results and lessons learnt will be widely shared with stakeholders for their implementation and streamlining in health system

Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: results of a cross-sectional baseline survey

Background: Although Pakistan was one of the first countries in Asia to launch national family planning programs, current modern contraceptive use stands at only 26% with a method mix skewed toward short-acting and permanent methods. As part of a multiyear operational research study, a baseline survey was conducted to understand the predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the baseline survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed. Method: A cross-sectional baseline household survey was conducted with randomly selected 3,998 married women of reproductive age (MWRA) in the Chakwal, Mianwali, and Bhakkar districts of Punjab. The data were analyzed on SPSS 17.0 using simple descriptive and logistic regression. Results: Most of the women had low socio-economic status and were younger than 30 years of age. Four-fifths of the women consulted private sector health facilities for reproductive health services; proximity, availability of services, and good reputation of the provider were the main predicators for choosing the facilities. Husbands were reported as the key decision maker regarding health-seeking and family planning uptake. Overall, the current contraceptive use ranged from 17% to 21% across the districts: condoms and female sterilization were widely used methods. Woman’s age, husband’s education, wealth quintiles, spousal communication, location of last delivery, and favorable attitude toward contraception have an association with current contraceptive use. Unmet need for contraception was 40.6%, 36.6%, and 31.9% in Chakwal, Mianwali, and Bhakkar, respectively. Notably, more than one fifth of the women across the districts expressed willingness to use quality, affordable long-term family planning services in the future. Conclusion: The baseline results highlight the need for quality, affordable long-term family planning services close to women’s homes. Furthermore, targeted community mobilization and behavior change efforts can lead to increased awareness, acceptability, and use of family planning and birth spacing services

Exposure to low concentrations of heavy metals alone and in combination induces histopathological and genotoxic effects in fish (Labeo rohita)

Background: The terrestrial and agro-aquatic ecosystems are continuously at the pity of human's negative impacts. Extensive and indiscriminate application of agrochemicals like heavy metals, industrial wastes, germicides, drug residues and different feed additives has become serious threats to public health. The current experimental trial was executed to investigate genotoxic potential of different heavy metals in fresh water fish (Labeo rohita).Methods: A total of 120 active, healthy, free from  disease and internal parasites fish having three months of age were procured from local fish breeding center and were kept in glass aquarium having 100 liter water. After two weeks of acclimatization, fish were arbitrarily distributed and placed in different eight groups (A-H). Prior to start of experiment, acute toxicity of various heavy metals alone such as lead, cadmium, chromium and in combination (Pb +Cr), (Cr+Cd), (Cd+Pb) and (Pb+Cr+Cd) mixture were determined in-term of 96-h LC50 and lethal doses for Labeo rohita. After assessment of acute toxicity, all the fish were exposed to three sub-lethal concentrations (5, 7 and 9%) of heavy metals alone and in combinations for a period of 30 days in triplicate experiments.Results: Different clinical ailments like, increased surface breathing, loss of coordination, rapid opercular movement, erratic swimming, air gulping, jerking movement and tremors were noted in fish. Histopathological observations of gills of various fish exhibited severe microscopic alterations. Results on micronucleus assay exhibited increased frequency of formation of micronuclei in red blood cells, while comet assays showed significantly increased DNA damage in peripheral erythrocytes in-term of arbitrary units of comets, average percentile rate of damaged cell and genomic damage index.Conclusion: From the results of our experimental study, it can be concluded that fresh water fish are useful and reliable bio-indicators of heavy metal toxicity. Micronucleus and comet assays showed that heavy metals alone and in combination induced DNA damage in fish.Keywords: Labeo rohita; Heavy metals; Histopathology; Erythrocytes; DNA damag

Comparing effectiveness of active and passive client follow-up approaches in sustaining the continued use of long acting reversible contraceptives (LARC) in rural Punjab: A multicentre, non-inferiority trial

Background: The use of long-acting reversible contraceptive (LARC) methods is very low in Pakistan with high discontinuation rates mainly attributed to method-related side effects. Mixed evidence is available on the effectiveness of different client follow-up approaches used to ensure method continuation. We compared the effectiveness of active and passive follow-up approaches in sustaining the use of LARC-and within \u27active\u27 follow-up, we further compared a telephone versus home-based approach in rural Punjab, Pakistan.Methods: This was a 12-month multicentre non-inferiority trial conducted in twenty-two (16 rural- and 6 urban-based) franchised reproductive healthcare facilities in district Chakwal of Punjab province, between November 2013 and December 2014. The study comprised of three groups of LARC clients: a) home-based follow-up, b) telephone-based follow-up, and c) passive or needs-based follow-up. Participants in the first two study groups received counselling on scheduled follow-up from the field workers at 1, 3, 6, 9, and 12 month post-insertion whereas participants in the third group were asked to contact the health facility if in need of medical assistance relating to LARC method use. Study participants were recruited with equal allocation to each study group, but participants were not randomized. The analyses are based on 1,246 LARC (intra-uterine contraceptive device and implant) users that completed approximately 12-months of follow-up. The non-inferiority margin was kept at five percentage points for the comparison of active and passive follow-up and six percentage points for telephone and home-based approach. The primary outcome was cumulative probability of method continuation at 12-month among LARC users.Results: Women recruited in home-based, telephone-based, and passive groups were 400, 419 and 427, respectively. The cumulative probability of LARC continuation at 12 month was 87.6% (95% CI 83.8 to 90.6) among women who received home-based follow-up; 89.1% (95% CI 85.7, 91.8) who received telephone-based follow-up; and 83.8% (95% CI 79.8 to 87.1) who were in the passive or needs-based follow-up group. The probability of continuation among women who were actively followed-up by field health educators-either through home-based visit or telephone-based follow-up was, 88.3% (95% CI 85.9 to 90.0). An adjusted risk difference of -4.1 (95% CI -7.8 to -0.28; p-value = 0.035) was estimated between active and passive follow-up. Whereas, within the active client follow-up, the telephone-based follow-up was found to be as effective as the home-based follow-up with an adjusted risk difference of 1.8 (95% CI -2.7 to 6.4; p-value = 0.431).Conclusion: A passive follow-up approach was 5% inferior to an active follow-up approach; whereas telephone-based follow-up was as effective as the home-based visits in sustaining the use of LARC, and was far more resource efficient. Therefore, active follow-up could improve method continuation especially in the critical post-insertion period

Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions

Background: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society - Pakistan implemented an operational research project - ‘Evidence for Innovating to Save Lives’, to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. Methods: We conducted a quasi-experimental (pre - and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, 1) Suraj model (meaning ‘Sun’ in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and 2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata® version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. Results: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14 % percentage points, current contraceptive use by 5 % percentage points and long term modern method - intrauterine device (IUD) use by 6 % percentage points. The CMW model significantly increased contraceptive awareness by 28 % percentage points, ever use of contraceptives by 7 % percentage points and, IUD use by 3 % percentage points. Additionally the Suraj intervention led to a 35 % greater prevalence (prevalence ratio: 1.35, 95 % CI: 1.22–1.50) of contraceptive use among MWRA. Conclusion: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas