Mean-field solution of structural balance dynamics in nonzero temperature.

In signed networks with simultaneous friendly and hostile interactions, there is a general tendency to a global structural balance, based on the dynamical model of links status. Although the structural balance represents a state of the network with a lack of contentious situations, there are always tensions in real networks. To study such networks, we generalize the balance dynamics in nonzero temperatures. The presented model uses elements from Boltzmann-Gibbs statistical physics to assign an energy to each type of triad, and it introduces the temperature as a measure of tension tolerance of the network. Based on the mean-field solution of the model, we find out that the model undergoes a first-order phase transition from an imbalanced random state to structural balance with a critical temperature T_{c}, where in the case of T>T_{c} there is no chance to reach the balanced state. A main feature of the first-order phase transition is the occurrence of a hysteresis loop crossing the balanced and imbalanced regimes.

Preperitoneal repair of inguinal hernia at open radical prostatectomy.

PURPOSE: Patients undergoing prostatectomy for cancer are at risk for onset/worsening of inguinal hernia (IH). Preperitoneal inguinal hernia repair (IHR) concurrent with radical prostatectomy (RP) should be considered. Dissection of the preperitoneal space at RP provides an ideal opportunity for the repair of inguinal hernia. We describe our efforts with patients undergoing RP and IHR to determine whether this approach is safe. METHODS: Records of patients undergoing RP and simultaneous IHR were identified from a prospective prostatectomy database from 1995 to 2007. Clinical hernia presentation, repair techniques, operative time, and complications were recorded. RESULTS: During the study period, 4,311 RPs were performed at our institution. Of these, 108 patients (2.5%) had 141 simultaneous IHRs. The mean patient age was 61 years (range 45-79), with an average body mass index (BMI) of 27.5 (range 19-37.6). Most patients underwent repair of a unilateral IH (n = 75; 69%) and 33 patients (31%) had a bilateral repair. The operative time was a median of 224 min in patients undergoing simultaneous IHR compared with 180 min in patients undergoing RP only. Records of the time required for IHR were available for 21 patients undergoing unilateral repair and for 18 patients undergoing bilateral repair. The median times for unilateral and bilateral IHR were 42 and 33 min, respectively. Only one patient had postoperative complications (perineal discomfort, bilateral neuralgia/paresthesia) possibly related to IHR. There were no wound infections in patients undergoing simultaneous hernia repair. Of the 141 IH repairs, four recurrent hernias (2.8%) required reoperation at a median of 16 months following initial repair. CONCLUSIONS: In our experience, preperitoneal IHR at the time of RP should be strongly considered, as it is not associated with an increased risk of complications and adds less than an hour of additional operative time to RP alone.

Perspectives on domestic violence: case study from Karachi, Pakistan.

There is no adequate profile of domestic violence in Pakistan although this issue is frequently highlighted by the media. This case study used qualitative and quantitative methods to explore the nature and forms of domestic violence, circumstances, impact and coping mechanisms amongst selected women victims in Karachi. Violence was a continuum: all the women reported verbal abuse, often escalating into physical, emotional, sexual and economic abuse. The husband was the most common perpetrator. Women suffered in silence due to sociocultural norms, misinterpretation of religious beliefs, subordinate status, economic dependence and lack of legal redress. Besides short-term local measures, public policy informed by correct interpretation of religion can bring about a change in prevailing societal norms.

Using SERVQUAL for assessing and improving patient satisfaction at a rural health facility in Pakistan.

A cross-sectional study of patient satisfaction with care was conducted over a period of 1 year from March 2004 to March 2005 in a secondary-level hospital in a peri-urban area of Karachi, Pakistan. Using the SERVQUAL tool and exit interviews, data were collected quarterly from a total of 1533 patients. Results sharing and capacity-building workshops were arranged during the 4 phases of the survey to sensitize the staff of the hospital to work towards improving patient satisfaction. The level of satisfaction of the patients with the outpatient health services provided showed a gradual increase from 34.4% to 82.0% over the 1-year period.

Gender sensitization among health providers and communities through transformative learning tools: experiences from Karachi, Pakistan.

CONTEXT: Pakistan lags far behind most developing countries in women's health and gender equity. Appropriateness of health care services vis-a-vis the gender specific cultural norms that influence clients' needs are not very visible and are more difficult to monitor. Programs and services need to be sensitively designed to facilitate women's access to physical and social needs. This paper narrates the experience of working with health providers from public and private sectors, community, local government representatives and community-based organizations. Through transformative learning, this endeavour focused on initiating a process of sensitization on gender related health issues for women. APPROACH: The initiative was primarily based on the use of the following two standardized tools: 'Health Workers for Change' for working with health providers and 'Initiating Women Empowerment for Health' for interacting with the community. Both tools focus primarily on women's health and social issues affecting their health status. The research methodology used was predominantly qualitative, using focus group discussions, participatory rural appraisal and interactive workshops. IMPLICATIONS: This approach endeavours to sensitize the health service providers to the health needs of female clients and encourages behavioural changes. Simultaneously, it creates an opportunity to raise awareness among women and the community in general regarding appropriate health-seeking behaviour and the timely use of health services. The information collected is evidence for policy makers regarding the gender-based problems faced by women who are seeking health care and it suggests how to overcome these problems.

Health Workers for Change: a tool for promoting behaviour change among health providers.

Sensitizing health providers to customers' needs and women's health remains a challenge to the Pakistani health system. The Health Workers for Change methodology has been demonstrated to improve provider-client relationships in certain African and Latin American countries. This paper describes the experience of using Health Workers for Change participatory workshops in Pakistan to sensitize male and female health providers to gender issues. Health care providers identified the unmet needs of women clients as a function of individual, household and societal factors, and, unlike the African experience with this tool, not predominantly confined to factors associated with the health facility.

Health management information system: a tool to gauge patient satisfaction and quality of care.

The health management information system (HMIS) is an instrument which could be used to improve patient satisfaction with health services by tracking certain dimensions of service quality. Quality can be checked by comparing perceptions of services delivered with the expected standards. The objective of the HMIS would be to record information on health events and check the quality of services at different levels of health care. The importance of patient assessment is a part of the concept of giving importance to patient's views in improving the quality of health services. Expected benefits include enhancing patient satisfaction through improved communication; greater provider sensitivity towards patients; enhanced community awareness about the quality of services; and overall better use of services in the health system.

The district health system: a challenge that remains.

The health care system in Pakistan has been confronted with problems of inequity, scarcity of resources, inefficient and untrained human resources, gender insensitivity and structural mismanagement. With the precarious health status of the people and poor indicators of health in the region, health care reforms were finally launched by the government in 2001. There are, however, numerous challenges and constraints in the system. The future health of the nation depends on this decentralization initiative. All our efforts should be concerted to support and facilitate the new system, which will mature into institutionalization of the health services at the district level. Most importantly, it will help in strengthening the primary health care services catering to the major fraction of the population. Besides political commitment, we ought to maintain attitudinal, behavioural and cultural conditions conducive to letting this system flourish.

Tuberculosis: do we know enough? A study of patients and their families in an out-patient hospital setting in Karachi, Pakistan.

SETTING: In Pakistan approximately 5.7 million people suffer from tuberculosis, with 260 000 new cases occurring every year. This study was conducted in an outpatient hospital setting in Karachi. OBJECTIVE: To explore the level of awareness about tuberculosis amongst patients and their families, and recommend strategies for increasing understanding of the disease. DESIGN: Descriptive cross-sectional survey based on a structured questionnaire using convenience sampling. RESULTS: Of the 203 patients interviewed, 131 were males. Nearly 82% knew that tuberculosis is contagious and 78% were aware that lungs are commonly affected. Almost half knew that it spreads by droplets and causes cough and that treatment is long and costly. With regard to commonly affected age and sex, however, respectively only 43% and 23% had the correct knowledge. Less than one third could identify appropriate risk factors and ways to cure and limit spread. Almost half considered tuberculosis to be a social stigma. Media emerged as the main source of information. Respondents with more than 12 years of formal education were more likely to have better knowledge. CONCLUSIONS: Further population-based studies are recommended. Misconceptions about tuberculosis need to be removed through focused health education messages. The importance of complete and appropriate treatment needs to be emphasised.

The role of thoracotomy in managing postchemotherapy residual thoracic masses in patients with nonseminomatous germ cell tumours.

OBJECTIVE: To evaluate the clinical outcome and identify prognostic variables in patients with nonseminomatous germ cell tumours undergoing postchemotherapy thoracotomy for residual masses, as the role of this procedure is controversial. PATIENTS AND METHODS: Of 385 patients who underwent postchemotherapy retroperitoneal lymph node dissections between 1988 and 1998, 105 also had 130 thoracotomies. The clinical presentation, chemotherapy regimens, marker status, primary tumour histology, pathology of all resected masses, and clinical outcome of these 105 patients were analysed. RESULTS: The overall discordance rate for synchronous thoracic and retroperitoneal masses was 28%; that for asynchronous thoracic and retroperitoneal masses was 57%. Independent prognostic factors for residual thoracic teratoma or cancer were teratoma (mature or immature) in the primary tumour or retroperitoneal teratoma or cancer. Although three of 12 patients with residual thoracic cancer remained with no evidence of disease, residual thoracic cancer is an independent prognostic factor (P < 0.001) against disease-free survival. CONCLUSION: Postchemotherapy thoracotomy yields important prognostic information, and is therapeutic for most patients with teratoma and a subset with residual viable cancer. The prognostic criteria predictive of fibrosis are not sufficiently accurate to omit resection of residual thoracic masses.

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse.

PURPOSE: To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting. PATIENTS AND METHODS: Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months). RESULTS: Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers. CONCLUSION: Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

Upper-tract tumors after an initial diagnosis of bladder cancer: argument for long-term surveillance.

PURPOSE: To determine the relative risk (RR) of upper-tract tumors (UTT) after bladder cancer, stratified by bladder tumor characteristics, demographic factors, and follow-up duration, in order to develop an improved risk-based surveillance strategy. PATIENTS AND METHODS: The 1973 to 1996 Surveillance, Epidemiology, and End Results (SEER) database was used to determine the observed and expected number of UTT after bladder cancer. The RR with 95% confidence intervals (CI) were calculated, stratifying by race, sex, stage, grade, histology, and follow-up duration. The tumor characteristics and clinical outcome were compared in patients with UTT after bladder cancer and those with de novo UTT. RESULTS: A total of 94,591 patients had a first diagnosis of bladder cancer, of whom 91,245 had follow-up (median, 4.1 years), with no antecedent or synchronous UTT. UTT developed subsequently in 657 of 91,245 (0.7%), with 12.80 expected cases (RR = 51.3; 95% CI, 47.5 to 55.4). The respective RRs for UTT for white men and women were 64.2 (95% CI, 55.1 to 74.3) and 75.4 (95% CI, 57.7 to 96.9) at less than 2 years, 44.3 (95% CI, 36.7 to 53.0) and 40.5 (95% CI, 27.9 to 56.8) at 2 to 5 years, 50.8 (95% CI, 42.2 to 60.7) and 42.1 (95% CI, 28.8 to 59.4) at 5 to 10 years, and 43.2 (95% CI, 32.6 to 56.1) and 22.2 (95% CI, 10.1 to 42.2) at >or= 10 years. Similar RRs were seen among different strata of race, stage, grade, and histology. Patients with UTT after bladder cancer had lower stage and improved disease-specific survival compared with those with de novo UTT. CONCLUSION: The incidence of UTT is stable on long-term follow-up, with no significant risk factors identified. These findings suggest that upper-tract surveillance remain rigorous on extended follow-up of bladder cancer patients.

Behind the counter: pharmacies and dispensing patterns of pharmacy attendants in Karachi.

BACKGROUND: There is little literature available on dispensing patterns and unsupervised sale of medicines from pharmacies in developing countries. OBJECTIVE: This study obtained background information on pharmacies, assessed the level of training, knowledge and dispensing patterns of pharmacy attendants in Karachi. METHODOLOGY: This is a descriptive cross sectional study with convenient sampling. A structured questionnaire was used to interview pharmacy attendants. RESULTS: Of the 219 pharmacies surveyed, 62% reported more than 50 customers daily and 20% also sold items of general provision. Mean operating hours were 13. Only 24 (11%) had a visible license. On an average 3 attendants were employed per pharmacy. We interviewed one in each. Amongst the 219 interviewed, 77 (35%) were intermediate qualified and only 26 (12%) pharmacologically trained. Correct frequency of ORS administration was not known by 167 (76%) and 21% incorrectly suggested an anti-diarrhoeal preparation for viral diarrhoea in children. The knowledge of those with pharmacological training was significantly better. For respiratory tract infection in children approximately 60% did not know the correct dose of Paracetamol and Amoxicillin. Only 13 (6%) knew that Propanalol was contraindicated in hypertensive asthamatics. For Cotrimoxazole, metronidazole and lomotil only 40%, 21% and 15% respectively, were aware that these could not be dispensed without prescription. CONCLUSION: In the absence of trained pharmacists existing pharmacy attendants should be trained to improve drug-dispensing patterns.

Clinical spectrum of systemic lupus erythematosus at the Aga Khan University Hospital.

BACKGROUND: Systemic lupus erythematosus is a disease of unknown etiology, which at onest may involve only one organ system or be multisystemic. The aim of our study is to determine the clinical presentation of SLE patients presenting to AKUH to establish whether guidelines laid down about this disease are in agreement with our experience. METHODS: A retrospective log review was carried out at AKUH, based on data obtained from 165 files of individuals admitted to the hospital over a period of 12 years with a confirmed diagnosis of SLE. RESULTS: From the sample size of 165, 143 (86.7%) were females and 22 (13.3%) males. The mean age of diagnosis was 30.9 years. Frequency of symptomatology was observed to be in the following order: systemic 78.8%, musculoskeletal 63% and hematological 60.6%. Oninvestigation ANA levels were positive in 112 patients. CONCLUSION: Our result lead us to conclude that the classification set forth by the American Rheumatological Association is applicable to patients presenting with SLE in our setting.

Factors predicting recovery of erections after radical prostatectomy.

PURPOSE: Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function. MATERIALS AND METHODS: Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented. RESULTS: Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves. CONCLUSIONS: Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.

The minds of mothers: maternal mental health in an urban squatter settlement of Karachi.

BACKGROUND: Community-based information on maternal mental health in developing countries is meager and nearly non-existent in Pakistan. OBJECTIVE: To determine the proportion of probable cases of women with mental disorders and examine the associated conditions and risk factors which contribute to maternal mental ill-health. METHODS: With convenient sampling 260 mothers in an urban squatter settlement of Karachi were interviewed. The tools consisted of a household questionnaire collecting information on basic demographic and other characteristics and the Aga Khan University Anxiety and Depression Scale (AKUADS), an instrument to assess psychiatric morbidity. RESULTS: The proportion of probable cases of mental disorder was 28.8% (n = 75). Reviewing the gradient of responses the most frequently expressed psychiatric symptoms were "being worried" and "crying". Amongst somatic complaints the most frequently reported was headache. Study also suggests that women in the older age group (OR 2.30, CI 1.27-4.19, p = 0.0031) and those with longer duration of marriage (OR 1.80, CI 1.01-3.22, p = 0.032) are more likely to be mentally distressed. Arguments with husband (OR 5.0, CI 2.19-11.52, p = 0.00001) or in-laws (OR 2.43, CI 1.22-4.85, p = 0.0059), husband's unemployment (OR 4.1, CI 1.27-13.6, p = 0.0058), not having permanent source of income and lack of autonomy in making decisions significantly contributed towards mental illness. CONCLUSION: Approximately 1 out of 4 women suffer from mental illness. This is alarmingly high. Besides counseling in cases of matrimonial disharmony, community-based interventions should aim to improve the socioeconomic status of households.

Second primary malignancies associated with renal cell carcinoma: influence of histologic type.

OBJECTIVES: This study was performed to determine which histologic types of renal cell carcinoma have an association with a second primary malignancy. METHODS: Seven hundred sixty-three patients underwent an operation for renal cell carcinoma between July 1989 and January 1999. The incidence of antecedent, synchronous, or subsequent second malignancies was determined. Statistical tests based on the Poisson model were used to compare the observed number of subsequent malignancies developing after a diagnosis of renal cell carcinoma with the expected number calculated using the 1973 to 1994 U.S. Surveillance, Epidemiology, and End Results age, race, gender, and calendar-year specific incidence rates. RESULTS: Second primary malignancies were present in 209 of 763 (27.4%) patients, with prostate, breast, colon, and bladder cancer and non-Hodgkin's lymphoma being the five most common second malignancies. The other malignancies were antecedent in 118 cases (44.5%), synchronous in 104 cases (39.2%), and subsequent in 43 cases (16.2%). Patients with papillary renal cell carcinoma were at increased risk of developing bladder cancer (standardized incidence ratio [SIR] 6.5, P = 0.038). Men with papillary renal cell carcinoma were also at increased risk of developing prostate cancer (SIR 2.8, P = 0.035). CONCLUSIONS: There is an increased risk of subsequent bladder and prostate cancer in patients with papillary renal cell carcinoma.

Mutation of cell cycle regulators and their impact on superficial bladder cancer.

Early cytogenetic studies in bladder cancer identify regions of chromosomal gain or loss that can be candidate loci for oncogenes and tumor suppressor genes. Oncogenes with potential prognostic significance identified in bladder cancer the RAS family, epidermal growth factor receptor, ERBB-2, MDM2, and cyclin D1. The TP53 gene has been the most thoroughly characterized tumor suppressor gene in bladder cancer, with correlation of TP53 alterations with type of carcinogenic exposure, tumor stage and grade, as well as prognosis. Studies evaluating alterations of the retinoblastoma pathway have identified the retinoblastoma gene, RB, p161NK4A/CDKN2, and E2F-1 as tumor suppressor genes with potential prognostic significance in patients with bladder cancer. Better understanding of the genetic mechanisms underlying bladder tumor development and progression will allow better prevention, diagnosis, and treatment strategies.

Views about women's mental health: study in a squatter settlement of Karachi.

OBJECTIVE: Mental health of women is globally receiving particular attention. This study assessed community's view on certain aspects of women's mental health prior to introducing an intervention. SETTING: The study was conducted in an urban squatter settlement located in District West of Karachi in 1997 where the Aga Khan University has set up a Primary Health Care program in partnership with the communities. METHODS: Using convenient sampling, door to door household survey was conducted by medical students. RESULTS: Two hundred and eighty one residents were interviewed. Respondents were asked to list contributory factors which lead to mental distress in women. Two hundred and ten (75%) were able to list certain factors. The factors listed were; low family income (40%), dispute amongst spouses (30%), verbal abuse by in-laws (25%) and too many children (5%). When asked what women in the community did while they were mentally distressed 35% respondents reported that women talked to their husbands and 18% said counselling from a health provider was sought. Main channels of social support desired were; revenue generation (67%), membership of a women's group (11%) and training of local community women in counselling skills (10%). CONCLUSION: Signs of awareness about mental health issues are present even in marginalized communities of Pakistan. In order to improve the mental health of women interventions should primarily focus on raising family income.

Economic development and health status among the poor in squatter settlements of Karachi.

OBJECTIVE: Socioeconomic status is an important determinant of health outcome measures. This study examines and presents some of the important health outcomes amongst the higher and lower socioeconomic groups within the urban poor. SETTING: Data analysis is based on a Health and Demographic Survey conducted in urban squatter settlements of Karachi in 1996. METHODS: A structured questionnaire was administered to all households in the catchment area. The indicator used to assess economic status is ownership of assets. RESULTS: Comparison between the two economic levels shows that the lower socio-economic group was more likely to experience child mortality, (CI; 1.02-1.29, p = 0.02) have lower contraceptive usage (CI; 2.11-2.64; p < 0.001) and childhood immunization rates (CI; 2.08-2.40, p < 0.001). No significant association was observed between economic levels and prevalence of diarrhea. The housing, literacy and employment status was consistently better in the higher economic stratum who were more likely to be Pushto-Punjabi speaking as compared to the Sindhi speaking population. CONCLUSION: To have sustainable improvement in the health status of the poor, those who are most vulnerable need to be identified and programs aiming to improve health should also undertake broader development initiatives like raising family income.