Clinical spectrum and outcomes of neonatal candidiasis in a tertiary care hospital in Karachi, Pakistan

Introduction: Candidal infections are a serious problem in neonatal intensive care units, increasing morbidity and mortality in low birth weight infants in addition to escalating health-care costs. Studies exploring the epidemiology of candidiasis in developing country hospitals are rare. This retrospective case-control study aimed to evaluate epidemiology and risk factors associated with candidiasis in a neonatal intensive care unit in Karachi, Pakistan. Methodology: Cases (neonates (age \u3c 28days, (n = 45) with NICU discharge diagnosis of candidal sepsis or candidemia between January 1996 and December 2006 were matched with controls (newborns with discharge diagnoses other than the above during the same study period) for gender, gestational age, and admission within 72 hours of admission of an index case. Risk factors were identified and clinical course and outcomes (discharge disposition) described. P-value and match-adjusted odds ratios were calculated. Results: A frequency of 0.9% candidemia was documented in the NICU. The incidence was highest (46%) in VLBW (\u3c 1500gm). C. albicans was the leading causative organism (55%), and neonatal risk factors identified were mechanical ventilation (\u3e 7 days), positive bacterial culture, and duration of hospitalization of \u3e 7 days. Conclusions: Prolonged ventilation, positive bacterial blood culture, and prolonged duration of NICU stay were the major risk factors associated with newborn fungal sepsis in our center. Presence of antenatal care was a significant protective factor in our subset of neonatal population

Regular crabmeat consumers do not show increased urinary cadmium or beta-2-microglobulin levels compared to non-crabmeat consumers

Acknowledgements We acknowledge help from staff at Stromness surgery and Balfour hospital, NHS Orkney who collected and processed samples from the Orkney volunteers. We also gratefully acknowledge the contribution of the all volunteers who participated in the study. Financial Support This study was funded by grants from Orkney Fisherman’s Society Ltd and MacDuff Shellfish Ltd who themselves were awarded a grant from the UK Sea Fish Industry Authority’s (Seafish) Strategic Investment Programme 2015-2018. Neither Seafish, Orkney Fisherman’s Society Ltd nor MacDuff Shellfish Ltd had a role in the design, analysis, or writing of this study. The research of A.A.S. and S.B. is supported by Scottish Government’s Rural and Environment Science and Analytical Services Division (RESAS).Peer reviewedPostprin

Risk factors associated with birth asphyxia in rural district Matiari, Pakistan: A case control study

Background: During the past two decades there has been a sustained decline in child mortality; however, neonatal mortality has remained stagnant. Each year approximately 4 million babies are born asphyxiated resulting in 2 million neonatal deaths and intrapartum stillbirths. Almost all neonatal deaths occur in developing countries, where the majority is delivered at homes with negligible antenatal care and poor perinatal services.Objectives: To identify socio-demographic and clinical risk factors associated with birth asphyxia in Matiari District of Sindh Province, Pakistan.Method: A matched case control study was conducted in Matiari District with 246 cases and 492 controls. Newborn deaths with birth asphyxia diagnosed through verbal autopsy accreditation during 2005 and 2006 were taken as cases. Controls were the live births during the same period, matched on area of residence, gender and age.Result: The factors found to be associated with birth asphyxia mortality in Matiari District of Sindh Province, Pakistan are maternal education, history of stillbirths, pregnancy complications (including smelly or excessive vaginal discharge and anemia), intrapartum complications (including fever, prolong or difficult labour, breech delivery, cord around child’s neck, premature delivery, large baby size) and failure to establish spontaneous respiration after birth.Conclusion and Recommendation: There is an immediate need to develop strategies for early identification and management of factors associated with birth asphyxia by involving women, families, communities, community health workers, health professionals and policy makers. Community health workers should be trained for emergency obstetric care, basic newborn care including preliminary resuscitation measures to provide skilled birth attendance and encourage early recognition and referral

Correlations of milk and serum element concentrations with production and management traits in dairy cows

ACKNOWLEDGMENTS This research, including the Langhill experiment at Crichton Dairy Research Centre, and all authors were funded by the Scottish Government Rural Affairs, Food, and the Environment Strategic Research Portfolio 2016–2021. Samples collected before 2016 were collected as part of a Biotechnology and Biological Sciences Research Council project awarded to EW (grant no. BB/K002260/1) and TNM (grant no. BB/K002171/1). The authors gratefully acknowledge the high standard of work by all staff at Crichton Farm (Scotland's Rural College, Dumfries, Scotland) in the collection of samples and management of animals, and Ian Archibald (Scotland's Rural College, Edinburgh, Scotland) for managing the Langhill database and assisting with data extraction. The authors have not stated any conflicts of interest.Peer reviewedPublisher PD

A novel training simulator for portable ultrasound identification of incorrect newborn endotracheal tube placement – Observational diagnostic accuracy study protocol

Background: Endotracheal tube (ETT) placement is a critical procedure for newborns that are unable to breathe. Inadvertent esophageal intubation can lead to oxygen deprivation and consequent permanent neurological impairment. Current standard-of-care methods to confirm ETT placement in neonates (auscultation, colorimetric capnography, and chest x-ray) are time consuming or unreliable, especially in the stressful resuscitation environment. Point-of-care ultrasound (POCUS) of the neck has recently emerged as a powerful tool for detecting esophageal ETTs. It is accurate and fast, and is also easy to learn and perform, especially on children.Methods: This will be an observational diagnostic accuracy study consisting of two phases and conducted at the Aga Khan University Hospital in Karachi, Pakistan. In phase 1, neonatal health care providers that currently perform standard-of-care methods for ETT localization, regardless of experience in portable ultrasound, will undergo a two-hour training session. During this session, providers will learn to detect tracheal vs. esophageal ETTs using POCUS. The session will consist of a didactic component, hands-on training with a novel intubation ultrasound simulator, and practice with stable, ventilated newborns. At the end of the session, the providers will undergo an objective structured assessment of technical skills, as well as an evaluation of their ability to differentiate between tracheal and esophageal endotracheal tubes. In phase 2, newborns requiring intubation will be assessed for ETT location via POCUS, at the same time as standard-of-care methods. The initial 2 months of phase 2 will include a quality assurance component to ensure the POCUS accuracy of trained providers. The primary outcome of the study is to determine the accuracy of neck POCUS for ETT location when performed by neonatal providers with focused POCUS training, and the secondary outcome is to determine whether neck POCUS is faster than standard-of-care methods.Discussion: This study represents the first large investigation of the benefits of POCUS for ETT confirmation in the sickest newborns undergoing intubations for respiratory support

Bovine lactoferrin to prevent neonatal infections in low-birth-weight newborns in Pakistan: Protocol for a three-arm double-blind randomized controlled trial

Background: Sepsis is a common and severe complication in premature neonates, particularly those born with low birth weights (\u3c2500 \u3eg). Neonatal sepsis is steadily emerging as a leading cause of neonatal mortality in Pakistan. Lactoferrin is a natural product with broad-spectrum antimicrobial properties and glycoprotein that is actively involved in innate immune host responses. Clinical trials have revealed its protective effect on sepsis, but lactoferrin dosage, duration, and role in the prevention of sepsis are still uncertain.Objective: We aimed to establish the efficacy of bovine lactoferrin in the prevention of late-onset sepsis and to determine the optimal dose and method of administering bovine lactoferrin that may contribute to improvement in overall survival of low birth weight infants.Methods: We will implement the study in 2 phases at the Aga Khan University Hospital. The first phase, which we have completed, was formative research. This phase mainly focused on a qualitative exploration of perceptions about feeding and caring practices of low birth weight newborns and a trial of improved practices for the preparation and administration of bovine lactoferrin to newborns. The second phase is a 3-arm double-blind randomized controlled trial. In this phase, we randomly allocated 2 different daily oral prophylactic doses of bovine lactoferrin (150 mg or 300 mg) and placebo to 300 low-birth weight neonates starting within the first 72 hours of birth and continuing for the first 28 days of life.Results: The study protocol was approved by the Ethics Review Committee of Aga Khan University on August 16, 2017. Data collection began in April 2018 and was completed in September 2020. Data analyses are yet to be completed. We expect the results to be published in peer-reviewed journals by autumn of 2021.Conclusions: This intervention, if effective, has the potential to be translated into a safe, affordable, and widely utilized treatment to prevent sepsis and, subsequently, may improve the survival outcomes of low birth weight neonates in Pakistan and other low- and middle-income countries.Trial registration: ClinicalTrials.gov NCT03431558; https://clinicaltrials.gov/ct2/show/NCT03431558.International registered report identifier (irrid): PRR1-10.2196/23994

Contextual challenges in the implementation of the alliance for maternal and newborn health improvement, prospective cohort study, an experience from rural Pakistan

Introduction: Improving maternal and newborn survival needs robust data on patterns of morbidity and mortality from well-characterized cohorts. It is equally important for researchers to document and understand the contextual challenges of data collection and how they are addressed. Methods: This was a prospective cohort study implemented from December 2012 to August 2014 in Matiari, Pakistan. A total of 11,315 pregnancies were enrolled. Participants were approached at home for sequential data collection through the standard pretested structured questionnaires. Some indicators were sourced through health facility records. Information on field challenges gathered through field diaries and minutes of meetings with field staff. Results: Inaccurate reporting of last menstrual period (LMP) dates caused difficulties in the planning and completion of antenatal data collection visits at scheduled gestational weeks. We documented ultrasound reports wherever available, relied on quickening technique, and implemented a seasonal event calendar to help mothers’ recall their LMP. Health system coordinators of public sector and private healthcare providers were individually approached for maximum data collection. But an unregulated private health system with poor record maintenance and health care providers’ reluctance for cooperation posed a greater challenge in data collection. Conclusions: Within a broader understanding of the health systems and socio-cultural environment, temporal and spatial feasibility of data collection should be considered thoroughly at the early stages of study designing, planning, resource allocation, and implementation. Pre-defined regular and need-based meetings with each tier of data collection teams and study managers help to reinvigorate field execution plans and optimize both quantity and quality of study data

Simulator-based ultrasound training for identification of endotracheal tube placement in a neonatal intensive care unit using point of care ultrasound

Background: Simulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.Methods: Sixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.Results: The majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p \u3c 0.001. There was an average reduction of 1.3 s (β = - 1.3; 95% CI: - 1.66 to - 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.Conclusion: We found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings

Effectiveness of specialized nutritious foods and social and behavior change communication interventions to prevent stunting among children in Badakhshan, Afghanistan: Protocol for a quasi-experimental study

Stunting predominantly occurs during the first 1000 days of life and continues to the age of five years. We will aim to assess the effectiveness of specialized nutritious foods (SNF)and social and behavior change communication (SBCC) strategies during the first 1000 days of life to prevent stunting among children in two rural districts of Badakhshan, Afghanistan. This will be a quasi-experimental pre-post study with the control group utilizing qualitative and quantitative methods. Before launching the program, formative research will be conducted on the acceptability, appropriate use and SBCC strategies needed to support the introduction of intervention package. Repeated cross-sectional baseline and endline surveys will be conducted in both the intervention and the control districts. After the formative research and baseline household survey, an intervention focusing on the provision of SNF, targeting pregnant and lactating women and children 6-23 months, and SBCC strategies will be implemented for at least 12 months. The primary outcome will be a reduction in the prevalence of stunting among children under two years in the intervention group compared to the control group. We will aim to compare the intervention and control group between the pre- and post-intervention assessments to isolate the effect of the intervention by difference-in-differences estimates. The program monitoring and evaluation component will examine the quality of implementation, acceptability of intervention, identification of potential barriers and to learn how to enhance the program\u27s effectiveness through ongoing operational improvements. The results will be beneficial to design interventions to prevent stunting within Afghanistan and other low-middle-income countries

Exchangeable zinc pool size at birth in Pakistani small for gestational age and appropriate for gestational age infants do not differ but are lower than in US infants

Objectives: Small for gestational age (SGA) infants are more susceptible to infectious morbidity and growth faltering compared to their appropriate for gestational age (AGA) counterparts. Zinc supplementation of SGA infants may be beneficial but the underlying susceptibility to zinc deficiency of SGA infants has not been examined.Methods: In a community-based, observational, longitudinal study in a peri-urban settlement of Karachi, Pakistan, we compared the size of the exchangeable zinc pools (EZPs) in term SGA and AGA infants at birth and at 6 months of age, hypothesizing that the EZP would be lower in the SGA group. To measure EZP size, a zinc stable isotope was intravenously administered within 48 hours of birth (n = 17 and 22) at 6 months (n = 11 and 14) in SGA and AGA infants, respectively. Isotopic enrichment in urine was used to determine EZP.Results: No significant difference was detected in the mean (±standard deviation) EZP between SGA and AGA infants at birth, with values of 9.8 ± 3.5 and 10.1 ± 4.1 mg/kg, respectively (P = 0.86), or at 6 months. Longitudinal EZP measurements demonstrated a significant decline in EZP relative to body weight in both groups at 6 months (P \u3c 0.001). Mean EZP (adjusted for body weight) size at birth for the combined Pakistani groups was significantly lower than AGA infants at birth in the United States (P = 0.017).Conclusions: These results did not support a difference in zinc endowment between SGA and AGA Pakistani infants. They, however, do suggest lower in utero zinc transfer to the fetus in a setting where poor maternal nutritional status may confer a high susceptibility to postnatal zinc deficiency