Implementation of an infant male circumcision programme, Pakistan

Objective: To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan.Methods: Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1-92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression.Findings: Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1-30 days of age: 31-60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31-3.15; 61-92 days: aOR: 2.14; 95% CI: 1.13-4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant).Conclusion: Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger

Green technology: synthesis of iron-modified biochar derived from pine cones to remove azithromycin and ciprofloxacin from water

The rise of antibiotic pollutants in water threatens ecosystems and human health. Iron-modified biochar (BC) exhibits adsorption properties and offers a promising approach for effective environmental remediation. The current study explored the potential of iron-loaded biochar synthesized from pine cones for antibiotic removal from water. In this study, pine cones, a sustainable and renewable source, were used to produce iron-modified biochar and employed to remove azithromycin, ciprofloxacin, and their mixture from aqueous solutions. Biochar was synthesized through pyrolysis and modified by the addition of iron salts. The analysis of iron-modified biochar by Fourier-transform infrared spectroscopy (FT-IR), X-ray diffraction (XRD), and scanning electron microscopy (SEM) suggested a crystalline structure rich in minerals and functional groups (O–H, C=O, and C≡C) and loaded with iron, having plate-like roughness and distorted morphology along with sharp edges and corners. Antibiotic removal was evaluated by changing physical parameters, including biochar dose, pH, and temperature. The maximum removal percentages of azithromycin, ciprofloxacin, and their mixture were obtained as 87.8%, 91.3%, and 84%, respectively, at low pH, a low Fe-modified biochar dose, and higher temperature. Application of kinetic models suggested that the adsorption of antibiotics on iron-modified biochar is more inclined toward pseudo-second-order (R2 > 0.98) kinetics, indicating a chemisorption nature of the adsorption process. The findings highlight the potential of iron-modified biochar for removing antibiotics from aqueous solutions

The impact of socioeconomic factors on the outcome of childhood acute lymphoblastic leukemia (ALL) treatment in a low/middle income country (LMIC)

Survival for childhood acute lymphoblastic leukemia (ALL) has improved significantly, but these benefits may not be available to many children from low and middle income countries, where reasons for treatment failure may be unique to their environment. We retrospectively reviewed data on pediatric (1 to 18 y or younger) patients with newly diagnosed ALL treated over 5 years at a children\u27s cancer hospital in Pakistan. Patients were treated with modified Berlin-Frankfurt-Muenster -based therapy without risk stratification. There were 255 children with a median age of 7 years (mean, 7.65 y) and a male preponderance (M:F=1.6:1). 20% had T-ALL, one-third had white blood cells \u3e50×10/L and 13.7% central nervous system disease. A majority (56.5%) was malnourished. In total, 49 (19.2%) died before the end of induction and 21 died in complete remission. Most deaths were infection-related. A total of 50 patients relapsed and 19 abandoned therapy after complete remission. Five-year overall survival is 52.9% with abandonment censored and 45.8% with abandonment as an event. Overall survival was related to socioeconomic status but not to known risk factors. The outcome of ALL at our center is suboptimal and associated with factors not commonly seen in developed countries. Special attention to early diagnosis, infection control, and parental educational are needed to improve the survival

Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country

Abstract Background Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted. Methods Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0. Results Four hundred sixty-eight patients met the study’s inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1–4 shocks given during CPR (aOR (95% CI) 2.2 (1.3–3.6), 1.9 (1.0–3.7), 14.6 (4.9–43.4), and 3.0 (1.4–6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9–6.5), 1.4 (0.5–3.8), 5.3 (1.5–18.4), and 3.1 (1.0–10.2) respectively). Conclusion Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes

Reported Male Circumcision Practices in a Muslim-Majority Setting

Introduction. Male circumcision is a recommended practice in Muslim tradition. It is important to ensure that this procedure is performed as safely as possible in these communities. Methods. Five hundred adult men and women with at least one male child less than 18 years were interviewed in Karachi, Pakistan, regarding details of their child’s circumcision. The survey focused on actual and perceived delays in circumcision and perceptions about appropriate age and reasons and benefits and complications of the procedure. Circumcisions done after two months of age were defined as delayed. Results. Religious requirement was the primary reason for circumcision in 92.6% of children. However, 89.6% of respondents were of the opinion that circumcision had medical benefits as well. Half of the children (54.1%) had delayed circumcision (range 2.5 months to 13 years), even though 81.2% of parents were of the opinion that circumcisions should be done within 60 days of birth. Facility-delivered babies had less delay in circumcisions (49.1%) as compared to home-delivered babies (60.5%). Conclusion. Understanding the perceptions and practices around male circumcision can help guide national strategies for designing and implementing safe circumcision programs in Muslim-majority settings, with the potential to benefit an annual birth cohort of 20–25 million boys worldwide

Development of a tool for objectively measuring somatic pain in the low back region based on a longitudinal diagnostic study conducted in Karachi, Pakistan

Objectives This study aimed at devising an objective method for quantifying pain in the low back region using pressure pain threshold (PPT) and demographic factors as predictive variables.Methods The research was conducted in two phases. Phase I was a longitudinal exploratory study conducted on 49 men aged 18–50 years with chronic low back pain (CLBP) recruited using non-probability purposive sampling. We used Visual Analogue Scale to record pain intensity and pain affect, and Disability Rating Index to record associated disability. PPT was measured on 12 different locations on the lower back using a manual algometer. These measurements were taken from each participant in 1 to 6-follow-up visits, depending on improvement in the individual’s symptoms. In phase II additional 33 subjects, both men and women with varying durations of low back pain were recruited using non-probability convenience sampling. Repeated measures ordinal regression and receiver’s operating characteristic curve analyses were performed to develop predictive models using STATA V.16.0 and R V.3.5.2 software. These models were given an interface using Microsoft Excel. A p value of <0.05 was considered statistically significant.Results Higher PPT scores, increased lean body mass, lean physique and a longer duration of CLBP were associated with a reduction in CLBP intensity, affect and disability. Advancing age was associated with an increase in these outcomes. Collectively, these factors were found to predict pain intensity, affect, and disability with 63%–65% diagnostic accuracy in phase I, however, this diagnostic accuracy increased to 65%–78% in phase II.Conclusion We developed a new outcome tool ‘Pain Calculator’ that can objectively measure low back pain with sufficient statistical accuracy. With further refinement, this tool in the future can be configured to measure somatic pain in different regions as well, affording clinicians and researchers much-needed objectivity while recording pain levels.Trial registration number NCT04482075

Predictors of treatment abandonment for patients with pediatric cancer at Indus children cancer hospital, Karachi, Pakistan

Background: Abandonment of treatment is one of the toughest challenges to deal with in pediatric oncology. It leads to unnecessary mortality and morbidity in patients from low- and middle-income countries.Procedure: The objective of our retrospective study was to determine the prevalence and predictors for abandonment among children with cancer at our hospital in Karachi, Pakistan. We analyzed data on patients younger than 18 years, diagnosed with any malignancy between November 2014 and May 2016.Results: From a total of 821 patients, one hundred and eighty-two (22.2%) patients abandoned treatment at various stages, 92 (11.2%) patients did not initiate treatment at all, and the remaining 90 (11.0%) left during treatment. The gender ratio at registration was skewed toward males but not statistically significant for abandonment. Of 295 registered females, 74 (25.1%) abandoned treatment compared to 108 (20.5%) abandonments among 526 males. In multivariable regression analysis, the type of malignancy, guardian\u27s profession, and travelling from outside the city of Karachi (odds ratio [OR]: 1.48; 95% confidence interval [CI] 1.02-2.15; P = 0.039) correlated with increased abandonment. Treatment abandonment was higher among patients with brain tumors (45.7%) and solid tumors (30.8%) and among those whose guardians were associated with a rural profession (24.7%). Monthly income, age, and number of siblings had no impact on the decision to abandon treatment.Conclusion: Despite the provision of free treatment, the prevalence of abandonment was high. More qualitative data need to be collected to identify and target groups of individuals who may be likely to abandon treatment, thus improving outcome of patients

Histopathological and microbiological findings and diagnostic performance of GeneXpert in clinically suspected tuberculous lymphadenitis

Objectives: The primary objective was to determine the association between histopathological and microbiological findings in patients clinically suspected to have tuberculous lymphadenitis. A secondary objective was to assess the diagnostic utility of GeneXpert in lymph node specimens. Method: This was a single-centre prospective cohort study, performed in the Infectious Disease Clinic at The Indus Hospital. Three hundred and forty-one adult patients with chronically enlarged, accessible lymph nodes were enrolled after obtaining verbal consent, between February 2013 and April 2016. Tissue specimens were processed for histopathology, acid-fast bacillus (AFB) microscopy, AFB culture, and GeneXpert. Based on these results, anti-tuberculosis therapy (ATT) was prescribed. Clinical characteristics and treatment outcomes were recorded. Results: There were 297 evaluable patients; 74.4% were diagnosed with tuberculous lymphadenitis (TBLA), 6.7% with a malignancy, and 12.8% with reactive nodes. TBLA was diagnosed on suggestive histopathology in 89.6% of cases, followed by GeneXpert (32.6%), mycobacterial culture (26.6%), and AFB smear positivity (12.5%). The sensitivity of GeneXpert was 65.7% when assessed against AFB culture. Drug resistance was displayed by 8.2% of GeneXpert-positive cases and 11.7% of culture-positive cases. The majority of TBLA patients (88.7%) responded favorably to ATT. Conclusions: In light of laboratory evidence, a quarter of patients suspected of TBLA had an alternative diagnosis, highlighting its importance in avoiding over-treatment and diagnostic delays in malignancy. Although sensitivity is poor, the demonstration of drug resistance by both GeneXpert and AFB culture represents a useful tool to guide treatment. Keywords: Chronic granulomatous inflammation, Mycobacterial culture, GeneXpert, Malignancy, Reactive node

Inducting undergraduate medical students via WhatsApp-based multiple mini interviews during COVID-19 pandemic

Selection of medical students requires both cognitive and soft skills assessment. Shalamar Medical and Dental College (SMDC) has been using on-campus multiple mini interviews to assess the latter but due to Covid-19 pandemic it became imperative that an alternative be found. The aim of this communication is to share the process SMDC went through to plan, design, and ultimately conduct WhatsApp-based multiple mini interviews (wMMI) in a low risk method as an entry criteria for undergraduate medical students. The process involved designing scenarios appropriate for online interviews, training the faculty members regarding conducting MMI as well as the use of technology, and designing an online webpage for enrolling, scheduling and assessing candidates. We were able to successfully complete wMMI process for 522 candidates within one week in a low risk setting using WhatsApp as communication medium with strong IT and administrative support. Keywords: Medical student; Admission; Selection; Multiple mini interviews

Evaluation of baseline cardiac function by echocardiography and its association with nutritional status in pediatric cancer patients at the Indus hospital in Karachi, Pakistan

Introduction: Evidence on conducting baseline echocardiogram before starting chemotherapy in pediatric cancer patients is limited from developing countries where malnutrition and infections are common and which may result in cardiac dysfunction.Materials and Methods: A prospective, observational study was conducted from October 2016 to May 2017 at The Indus Hospital, Karachi, Pakistan, among children 1 to 16 years of age suffering from cancer. Echocardiography was performed before starting chemotherapy. Associations between body mass index and cardiac abnormalities were studied.Results: A total of 384 children met the inclusion criteria. The median (interquartile range) age was 8.0 (5.0 to 12.0) years and 62.0% (n=238) were male individuals. Twenty-two of 384 (5.7%) children had systolic dysfunction. Four of 22 had moderate-systolic and one of 22 had mild systolic dysfunction, for whom the therapy was altered, and they were treated without anthracyclines. Four of these 5 patients died, and only 1 of 5 survived through high-risk protocol. Seventeen of 22 children had low-normal systolic dysfunction. We found no evidence of an association between body mass index for age and abnormal left ventricular ejection fraction and abnormal fractional shortening (P-trend=0.587; 0.487, respectively). No associations were found of weight-for-age and height-for-age with these outcomes.Conclusions: In developing countries, echocardiograms should be expeditiously performed and technology made more accessible to rule out cardiac dysfunction and avoid delay in chemotherapy. Malnutrition was not associated with cardiac dysfunction