Genetic characterization of human coxsackievirus A6 variants associated with atypical hand, foot and mouth disease: a potential role of recombination in emergence and pathogenicity

Human coxsackievirus A6 (CVA6) is an enterically transmitted enterovirus. Until recently, CVA6 infections were considered as being of minor clinical significance, and only rarely aetiologically linked with hand, foot and mouth disease (HFMD) associated with other species A enteroviruses (particularly EV71 and CVA16). From 2008 onwards, however, CVA6 infections have been associated with several outbreaks worldwide of atypical HFMD (aHFMD) accompanied by a varicelliform rash. We recently reported CVA6-associated eczema herpeticum occurring predominantly in children and young adults in Edinburgh in January and February 2014. To investigate genetic determinants of novel clinical phenotypes of CVA6, we genetically characterized and analysed CVA6 variants associated with eczema herpeticum in Edinburgh in 2014 and those with aHFMD in CAV isolates collected from 2008. A total of eight recombinant forms (RFs) have circulated worldwide over the past 10 years, with the particularly recent appearance of RF-H associated with eczema herpeticum cases in Edinburgh in 2014. Comparison of phylogenies and divergence of complete genome sequences of CVA6 identified recombination breakpoints in 2A-2C, within VP3, and between 5' untranslated region and VP1. A Bayesian temporal reconstruction of CVA6 evolution since 2004 provided estimates of dates and the actual recombination events that generated more recently appearing recombination groups (RF-E, -F, -G and -H). Associations were observed between recombination groups and clinical presentations of herpangina, aHFMD and eczema herpeticum, but not with VP1 or other structural genes. These observations provided evidence that NS gene regions may potentially contribute to clinical phenotypes and outcomes of CVA6 infection

Prevalence and perceptions about consanguineous marriages among patients presenting to family physicians, in 2001 at a teaching hospital in Karachi, Pakistan

Aim: Consanguineous marriages are common in Pakistan despite their declining popularity in the developed world. In the present study, a questionnaire based survey was used to record the attitudes and perceptions of consanguineous marriages among the sample population. Methods: A questionnaire was developed to collect information on the acceptability of, and perceptions about, consanguineous marriages among patients presenting to family physicians, at the Family Practice Center of the Aga Khan University Hospital in Karachi, Pakistan. Demographic data was collected as part of the questionnaire. Each participating patient signed a consent form after assurance of confidentiality was provided. Results: A total of 393 patients were surveyed. The mean age of the study population was 29.4 years, 165 (42%) were men and 228 (58%) were women. The majority were married, well educated and were students, in private or government service or self employed. One hundred (25%) of the respondents were either married or were planning to marry their first cousin, and 57 (14%) their second cousin. The main reasons in favor of consanguineous marriages were quoted as: ‘arranged marriage’, ‘it is healthy to marry within the family’ and ‘it is traditional’. Some 271 (69%) of the respondents said ‘yes’ to their son or daughter marrying within the family. Constraints of religion, status, caste, family differences and the fear of incompatibility were among the reasons quoted as difficulties in finding a mate outside the family. Neurological diseases, diabetes mellitus and hypertension were quoted as diseases resulting from consanguineous marriages. Security of knowing the mate in the family, culture and religion, and having more information about the mate before marriage were quoted as reasons for the continued popularity of consanguineous marriages in Pakistan. Conclusions: The present study demonstrated a high degree of acceptability of consanguineous marriages among the study population and documented factors influencing such marriages. We recommend further studies, intervention strategies and debate on the issue

Project DIANA - Converging and Integrating IP and ATM for real-time applications

The evolution of IP and ATM share some common drivers. Both of them are addressing efficient network resource utilisation. In order to evaluate the options and combinations offered by these technologies the DIANA project is looking into the areas where ATM and IP both overlap and complete each other, that is QoS interworking between ATM and IP. This is achieved by investigating RSVP-over-ATM approach. This solution is compared with two IP level approaches: Differentiated Services and Scalable Resource Reservation Protocol (SRP)

Consequences of a medical emergency among emergency room patients

Objective: To study the consequences of a medical emergency among Emergency Room patients, at a teaching hospital in Karachi, Pakistan. Design: A questionnaire-based survey Settings: Emergency Room of Aga Khan University Hospital in Karachi, Pakistan. Main outcome measures: Consequences of a medical emergency in terms of impact on employment, financial position, family life, social life, recreational life, self-confidence and psyche. Results: A hundred patients were surveyed. Emergency Room patients feel that they will not have a major impact on their job or employment, as a result of the medical emergency but it will have adverse financial consequences. The respondents in our study perceive the consequence of the medical emergency to have a variable impact on their family life, social life, recreation life and self-confidence. It is important to note with concern that a major impact on ìPsycheî is expected by the emergency room patients, as a result of a medical emergencyConclusion: We have documented the consequences of a medical emergency among Emergency Room patients, with implications for medical practice and policy makers on healt

Patient expectations from an emergency medical service

BACKGROUND: Patient expectation survey at the Emergency Medical Services can improve patient satisfaction. A need was established to conduct such a survey in order to recommend its use as a quality improvement tool. METHODS: The study was conducted on patients visiting the Emergency Medical Services, Aga Khan University, Karachi. A questionnaire was used to collect information on the demographic profile, and expectations of patients. The ethical requirements for conducting the study were met. RESULTS: A hundred patients were surveyed. The majority was relatively young, married men and women, well educated and better socio-economically placed. The majority of the patients expected a waiting time and a consultation time of less than 30 minutes and 20 minutes, respectively. The majority of respondents expected and agreed to be examined by a trainee but there were reluctant to be examined by the students. There was an expectation that the consultant will examine patients and not advice the attending team over the phone. The majority of the patients expected intravenous fluid therapy. There was a desire to have patient attendant present during the consultation process. The majority of the patients expected to pay less than three thousand rupees for the visit. An expectation exists for investigations and hospitalization. Involvement of patients in decisions concerning their treatment and written feedback on their visit was expected. CONCLUSIONS: We have documented the need and value of patient expectation survey at the Emergency Medical Services department. The use of such a tool is recommended in order to improve the satisfaction levels of patients visiting such facilities

Implications for the practice of a patient expectation and satisfaction survey, at a teaching hospital in Karachi, Pakistan

Objective: To study the expectations and satisfaction of patients visiting Family Practice Clinics, at the Aga Khan University Hospital, in Karachi, Pakistan. Methodology: A cross sectional survey of 316 patients was carried out. A questionnaire, based on the study objectives was developed and administered. The participating patient signed a consent form, after assurance of confidentiality was provided. Data on the demographic profile of the patients was collected.Results: The mean age was 33.81 years, with 105 (33.2%) women, and 211 (66.8%) men. The majority were married, with education above intermediate level and were in private or government service or were housewives. The median for the patient waiting time was 30 minutes, against an expectation of 12.69 minutes. Reading newspaper, watching television, reading magazine, reading Quran and listening to music were quoted as ways to lessen the burden of waiting to see a physician. The average consultation time with the physician was 13.89 minutes, against an expectation of 16.37 minutes. Patient expectation in terms of listening by the doctor with patience, explanation of the diagnosis and treatment, prescription of medicines, ordering of investigations and specialist referral has been documented. Objections to the presence of medical student, nursing student, resident doctor, nurse and an observer, in the consultation room have also been documented. Reasons quoted for the objection include issues of privacy/confidentiality, lack of justification, discomfort, and interference with the consultation process. The expected average cost for doctor’s consultation was Pakistani Rs. 124, while 196 (61.8%) of the respondents were satisfied with the consultation based on Rs. 70. Conclusion: We have collected important information to improve the services offered at our Family Practice clinics (JPMA 53:122;2003)

Depression in the elderly: Does family system play a role? A cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The most common geriatric psychiatric disorder is depression. The role of family systems in depression among the elderly has not been studied extensively. It has been suggested that urbanization promotes nucleation of family systems and a decrease in care and support for the elderly. We conducted this study in Karachi, a large urban city of Pakistan, to determine the relationship between the type of family system and depression. We also determined the prevalence of depression in the elderly, as well as correlation of depression with other important socio-demographic variables.</p> <p>Methods</p> <p>A cross-sectional study was carried out in the premises of a tertiary care hospital in Karachi, Pakistan. Questionnaire based interviews were conducted among the elderly people visiting the hospital. Depression was assessed using the 15-item Geriatric Depression Scale.</p> <p>Results</p> <p>Four hundred subjects aged 65 and above were interviewed. The age of majority of the subjects ranged from 65 to 74 years. Seventy eight percent of the subjects were male. The prevalence of depression was found to be 19.8%. Multiple logistic regression analysis revealed that the following were significant (<it>p < 0.05</it>) independent predictors of depression: nuclear family system, female sex, being single or divorced/widowed, unemployment and having a low level of education. The elderly living in a nuclear family system were 4.3 times more likely to suffer from depression than those living in a joint family system (AOR = 4.3 [95% CI = 2.4–7.6]).</p> <p>Conclusion</p> <p>The present study found that residing in a nuclear family system is a strong independent predictor of depression in the elderly. The prevalence of depression in the elderly population in our study was moderately high and a cause of concern. The transition in family systems towards nucleation may have a major deleterious effect on the physical and mental health of the elderly.</p