Characteristics of traumatic out-of-hospital cardiac arrest patients presenting to major centers in Karachi, Pakistan-A longitudinal cohort study

Background: Trauma is the leading cause of death for adults under 44 years of age. Survival after traumatic out-of-hospital cardiac arrest (OHCA) has been reported to be poor, and its epidemiology is not well defined. A few studies have reported better survival in response to pre-hospital life-saving interventions. Currently, no published data on traumatic cardiac arrests in the field exist from low- and lower middle-income countries. We aimed to explore the epidemiology and outcomes of traumatic OHCA patients from Karachi, Pakistan. We conducted a longitudinal cohort study at emergency departments (ED) of five major public and private hospitals of the city from January to April 2013. Data was collected on all adult patients (age 18 years or more) presenting to the hospitals directly from field with cardiac arrest and history of trauma using a structured questionnaire. Patients with do-not-resuscitate status and those referred from other hospitals were excluded.Results: During 3 months, a total of 187 patients were enrolled with mean age of 35.1 years. About 95% were men, and 68.4% had a penetrating injury. Even though half of the patients had a witnessed arrest, none received a bystander cardiopulmonary resuscitation (CPR). 83.4% were brought to the hospital in an ambulance, with median response and scene times of 3 and 2 min respectively; however, only 3 received any pre-hospital life-support interventions. One hundred eighty-one patients (96.7%) were pronounced dead on arrival to the ED, and of the remaining 6 patients, 4 received CPR in the EDs. Overall survival at the end of ED stay was 0%. Patients who received life-support interventions survived for longer time, though not clinically significant, as compared to those who did not (45 min vs. 35 min, p = 0.02).Conclusion: There was no survival after a traumatic OHCA in Karachi, Pakistan. Even though ambulances reached the scene in a very short time, pre-hospital interventions were largely absent. There is a strong need to strengthen our pre-hospital care system but most importantly train the general public to deal with emergencies and be able to provide timely bystander CPR

Estimation of the burden of out-of-hospital traumatic cardiac arrest in Karachi, Pakistan, using a cross-sectional capture-recapture analysis

Background: The burden of trauma-related-out-of-hospital cardiac arrest (OHCA) in developing countries like Pakistan remains largely unexplored due to a lack of organized pre-hospital systems. In order to estimate the burden, we used a two-sample capture-recapture method which has been used in several domains to estimate difficult-to-count populations.Methods: We obtained 3-month data from two sources: Records of two major EMS (emergency medical services) systems and five major hospitals providing coverage to the city\u27s population. All adults with traumatic OHCA were included. Information on variables such as name, age, gender, date and time of arrest, cause of arrest, and destination hospital were obtained for these cases and data were compared to obtain a matched sample. Utilizing an equation and different levels of restrictive criteria, estimates were obtained for burden.Results: The EMS records reported 788 and hospital records reported 344 cases of traumatic OHCA. The capture-recapture analysis estimated the annual traumatic OHCA incidence as 45.7/100,000 (95% CI: 44.2 to 47.3). Estimation of the burden from individual hospital or EMS records underestimated and calculated only 14.6% and 33.9% of the total burden, respectively. Most of the traumatic arrest victims had gunshot wound (GSW) (65.2%) followed by road traffic injuries (RTI) (20.8%).Conclusion: The actual burden of traumatic OHCA in Pakistan is larger than the burden reported by either the hospitals or EMS services alone. Most of the cases occurred due to GSW and RTI. A multipronged approach is required to manage the problem; from prevention to developing organized trauma care systems and training lay responders in pre-hospital trauma care is vital

Evaluation of Prunus domestica gum as a novel tablet binder

To evaluate binding potential of Prunus domestica gum in tablets formulations. Six tablet batches (F-1B to F-6B) were prepared by wet granulation method, containing Avicel pH 101 as diluent, sodium diclofenac as model drug using 10, 15 and 20 mg of Prunus domestica gum as binder and PVP K30 was used as standard binder. Magnesium stearate was used as lubricant. Flow properties of granules like bulk density, tapped density, Carr index, Hausner’s ratio, angle of repose as well as physical parameters of the compressed tablets including hardness, friability, thickness and disintegration time were determined and found to be satisfactory. The FTIR spectroscopic analysis showed that the formulation containing plant gum is compatible with the drug and other excipients used in tablets formulation. Hence the plant gum has role as a potential binder in tablets formulations. The dissolution profile showed that tablets formulations containing Prunus domestica gum 15 mg/200 mg of total weight of tablet as binder showed better results as compared to PVP K30.Para avaliar a propriedade aglutinante da goma Prunus domestica em formulações de comprimidos, seis lotes (F-1B para F-6B) foram preparados pelo método de granulação úmida, contendo Avicel pH 101 como diluente e diclofenaco de sódio como fármaco modelo, usando 10, 15 e 20 mg de goma de Prunus domestica como agente aglutinante e PVP K30 como aglutinante padrão. O estearato de magnésio foi utilizado como lubrificante. Propriedades de fluxo dos grânulos, como a densidade, índice de Carr, razão de Hausner, ângulo de repouso, bem como parâmetros físicos dos comprimidos, incluindo o tempo de dureza, friabilidade, espessura e desintegração foram determinados e se mostraram satisfatórios. A análise espectroscópica no FTIR mostrou que a formulação contendo goma vegetal é compatível com o fármaco e outros excipientes utilizados na formulação dos comprimidos. Assim, a goma vegetal tem papel potencial como aglutinante em formulações de comprimidos. O perfil de dissolução das formulações que contêm 15 mg/200 mg do peso total do comprimido em goma de Prunus domestica como aglutinante mostrou melhores resultados comparativamente ao PVP K30

Study Protocol: Validation and Adaptation of community-worker-administered stroke symptom questionnaire in a periurban Pakistani community to determine disease burden.

Background : Stroke is the second leading cause of mortality and the leading cause of disability in the world today. The disease burden is on the rise in developing nations, but there is scarcity of data from these regions to inform policy decisions. Stroke burden can be determined by clinical diagnosis alone in the public health context and is a far more feasible way to assess disease status in low- to middle-income countries like Pakistan. We aim to translate and adapt a validated stroke symptom questionnaire, train community health workers in its administration, and verify it against assessment by two trained neurologists. Methods/Design : This is a prospective study, which we aim to carry out in Ibrahim Hyderi, a periurban slum of Karachi. We translated into Urdu the questionnaire for verifying stroke free status (QVSFS), which is an internationally validated tool to assess the same. Two community health workers (CHW) will be identified and will receive training by neurologists, which will include teaching regarding stroke pathophysiology, symptomatology, and detection. They will be familiarized with the QVSFS, and their questionnaire administration will be assessed through roleplay. We intend to recruit 322 subjects from the same community and the CHWs will gather data on them. The same subjects will later be assessed by two trained neurologists, and the findings collaborated to validate those obtained by the CHWs. Sensitivity, specificity, positive and negative predictive values, and Cohen’s kappa will be determined for the CHW-administered ques tionnaire tested against assessment by two neurologists together and separately for the two CHWs. Data analysis will be done using SPSS version 19.0. Discussion ; The results of this study will determine if and how well CHW-administered questionnaires are at assessing stroke status in a community. This will facilitate use of the same as a practical alternative for stroke surveillance in the countr

Knowledge and attitudes about tetanus and rabies: a population-based survey from Karachi, Pakistan

OBJECTIVE: To evaluate public knowledge regarding predisposing factors, fatality and prevention of Tetanus and Rabies and attitudes toward vaccination and post-exposure prophylaxis. METHODS: A population-based, cross-sectional survey was conducted in all the 18 towns of Karachi, the largest metropolitan city of Pakistan, from December 2007 to January 2008. Men and women of more than 18 years of age were included in the study which used a self-reporting questionarre as its tool. RESULTS: There were 1201 people interviewed by the study. The majority of respondents had known or heard about Tetanus (n = 973; 81%) and rabies (n = 699; 58%). There were 29 (2.5%) reported dog bites on the subjects themselves and 218(18%) respondents reported dog bites among their family members during the preceeding one year. Only three (11%) of these dog bite victims received some kind of vaccine or post-exposure prophylaxis. The majority of the participants were not aware of the fatality of these diseases and the importance of vaccination and post-exposure prophylaxis. Of the total respondents, 563 (47%) reported an injury or wound during the preceeding one year. Of them, 426 (76%) received a Tetanus injection. Out of the total study population, 1019 (85%) respondents did not know that Tetanus could be a fatal disease, and 844 (70%) did not know that Tetanus could affect and kill newborns. Literate people and males were more likely to have adequate knowledge on multivariate analysis. CONCLUSION: Minor injuries and dog bites are a common occurrence in Karachi. Only a small proportion of these patients received post-exposure treatment. Most of the participants were not aware of the fatality of these diseases and the importance and affordability of vaccination in case of dog bites and minor trauma

A Dynamical Study of Risk Factors in Intracerebral Hemorrhage using Multivariate Approach

The purpose of this study is to investigate the effects of clinical covariates to the outcome of Intracerebral Hemorrhage (ICH) patients in terms of best fitted and excellent discriminate model of binary response variable. Clinical data of 985 patients with ICH have collected using the International classification of diseases, Ninth revision codes. The diagnosis of ICH was confirmed by neuro-imaging in all patients. Univariate analysis revealed that out of 88 covariates 46 were found to be significant (p\u3c0.05). The multivariable analysis using multiple logistic regressions, exhibited a significant negative relationship between ICH and hypertension. The improvement among ICH patients having hypertension was 0.5 (p=0.001, ARR=0.5, 95% C.I. 0.3 – 0.8). The improvement among ICH patients using antihypertensive medicine was 1.3 (p = 0.016, ARR=1.3, 95% C.I. 1.1 – 1.5). Thus present study showed that ICH has strong relationship with use of antihypertensive medicine. The improvement of patients who were using antihypertensive medicine at the time of discharge was 3.0 times (p \u3c 0.0001, ARR=3.0, 95% C.I. 2.7 – 3.2) as compared to those who did not use antihypertensive medicine. The change in ARR from 1.3 to 3.0 times shows that the use of antihypertensive medicine and ICH outcome variable are positively associated. The change in ARR of hypertensive range of SBP also indicates that the blood pressure range and ICH outcome variable are negatively associated. The neurological symptomatology, slurred speech and double vision are important factors of proposed statistical models. Moreover, a clear decrease was found in mental status from normal to coma in applicable model. Surgery is an important part of recovery, and estimated that the improvement among the ICH patients, who were treated with surgery, was 1.4 times with significant p-value in best fitted models. The complication of pneumonia during treatment of ICH subjects has highly significant negative association with outcome variable. Present Model has 0.892 area under the curve with sensitivity (0.852), specificity (0.793) and p-value (0.204). This indicates that the model gives the impression to fit quite well for predictive performance of the ICH outcome variable and the model is excellent model

Can trained field community workers identify stroke using a stroke symptom questionnaire as well as neurologists? Adaptation and validation of a community worker administered stroke symptom questionnaire in a peri-urban Pakistani community.

Background: Stroke is a leading cause of morbidity and mortality worldwide. There is a paucity of data from South Asia where stroke is highly prevalent. Validated tools administrable by Community Health Workers (CHWs) are required to identify stroke in the community in a resource strapped region such as this. Methods: The study was conducted in a transitional slum in Karachi, Pakistan. Questionnaire for Verifying Stroke-Free Status (QVSFS) was adapted and translated into Urdu. Two CHWs, trained by a neurologist, selected 322 community dwelling subjects using purposive sampling. Each CHW collected data independently which was validated by a vascular neurologist who directly examined each participant. To assess the effect of audit and feedback, data from the final 10% of the subjects was collected following a second training session for the CHWs. Sensitivity, specificity and Cohen’s kappa was determined for the CHW administered questionnaire against neurovascular assessment. Results: Mean age of participants was 56.5 years with 71% of participants being women. The sensitivity and specificity of the questionnaire of detecting stroke was 77.1% (CI: 64.1%–86.9%) and 85.8% (CI: 83.5%–87.5%). The chance corrected agreement using the Cohen’s Kappa statistic was 0.51 (CI: 0.38–0.60). Kappa ranged from 0.37 to 0.58 for each of the seven stroke symptoms. Hemianesthesia (72.9%) and hemiplegia (64.6%) were the most sensitive symptoms. The performance and agreement improved from moderate to substantial after audit and feedback. Conclusion: We found a reasonable sensitivity and specificity and moderate agreement between CHW administered QVSFS and assessment by a vascular neurologist

Cultivating capacities in community-based researchers in low-resource settings: Lessons from a participatory study on violence and mental health in Sri Lanka

Participatory methods, which rely heavily on community-based data collectors, are growing in popularity to deliver much-needed evidence on violence and mental health in low- and middle-income countries. These settings, along with local researchers, encounter the highest burden of violence and mental ill-health, with the fewest resources to respond. Despite increased focus on wellbeing for research participants and, to a lesser degree, professional researchers in such studies, the role-specific needs of community-based researchers receive scant attention. This co-produced paper draws insights from one group’s experience to identify rewards, challenges, and recommendations for supporting wellbeing and development of community-based researchers in sensitive participatory projects in low-resource settings. Twenty-one community-based researchers supporting a mixed-methods study on youth, violence and mental health in Sri Lanka submitted 63 reflexive structured journal entries across three rounds of data collection. We applied Attride-Stirling’s method for thematic analysis to explore peer researchers’ learning about research, violence and mental health; personal-professional boundaries; challenges in sensitive research; and experiences of support from the core team. Sri Lanka’s first study capturing experiences of diverse community-based researchers aims to inform the growing number of global health and development actors relying on such talent to deliver sensitive and emotionally difficult work in resource-limited and potentially volatile settings. Viewing participatory research as an opportunity for mutual learning among both community-based and professional researchers, we identify practice gaps and opportunities to foster respectful team dynamics and create generative and safe co-production projects for all parties. Intentional choices around communication, training, human and consumable resources, project design, and navigating instable research conditions can strengthen numerous personal and professional capacities across teams. Such individual and collective growth holds potential to benefit short- and long-term quality of evidence and inform action on critical issues, including violence and mental health, facing high-burden, low-resource contexts

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019 : a systematic analysis for the Global Burden of Disease Study 2020, Release 1

Background Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time. Methods For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dosespecific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in countryreported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development. Findings By 2019, global coverage of third-dose DTP (DTP3; 81.6% [95% uncertainty interval 80.4-82 .7]) more than doubled from levels estimated in 1980 (39.9% [37.5-42.1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38.5% [35.4-41.3] in 1980 to 83.6% [82.3-84.8] in 2019). Third- dose polio vaccine (Pol3) coverage also increased, from 42.6% (41.4-44.1) in 1980 to 79.8% (78.4-81.1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56.8 million (52.6-60. 9) to 14.5 million (13.4-15.9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019. Interpretation After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe