Predictors for poor daily weight gain in preterm neonates exposed to different dose regimens of caffeine in ICU- a retrospective cohort study.

BACKGROUND: With a wide therapeutic index, efficacy, ease of use, and other neuroprotective and respiratory benefits, caffeine citrate(CC) is currently the drug of choice for preterm neonates (PTNs). Caffeine-induced excessive energy expenditure, diuresis, natriuresis, and other CC-associated potential side-effects (CC-APSEs) result in lower daily-weight gain (WG) in premature neonates. This study aimed to evaluate the risk factors for daily-WG in neonates exposed to different dose regimens of caffeine in ICU. METHOD: This retrospective cohort study included neonates of ≤ 36weeks gestational age (GA) and received CC-therapy. The same participants were followed for data analysis in two postnatal phases: 15-28 and 29-42 days of life (DOL). Based on daily CC-dose, formed group-I (received; standard-doses = 5 mg/kg/day), group-II (received;>5-7 mg/kg/day), and group-III (received;>7 mg/kg/day). Prenatal and postnatal clinical characteristics, CC-regimen, daily-WG, CC-APSEs, and concomitant risk-factors, including daily-caloric intake, Parenteral-Nutrition duration, steroids, diuretics, and ibuprofen exposure, were analyzed separately for group-II and group-III using group-I as standard. Regression analysis was performed to evaluate the risk factors for daily-WG. RESULTS: Included 314 PTNs. During 15-28 DOL, the mean-daily-WG(MD-WG) was significantly higher in group-I than group-II [19.9 ± 0.70 g/kg/d vs. 17.7 ± 0.52 p = 0.036] and group-III [19.9 ± 0.70 g/kg/d vs. 16.8 ± 0.73 p < 0.001]. During 29-42 DOL the MD-WG of group-I was only significantly higher than group-III [21.7 ± 0.44 g/kg/d vs. 18.3 ± 0.41 g/kg/d p = 0.003] and comparable with group-II. During 15-28 DOL, observed CC-APSEs was significantly higher in group-II and III but during 29-42 DOL it was only significant in group-III. In the adjusted regression analysis for daily-WG during 15-28DOL, with respect to standard-dose, 5-7 mg/kg/day (ß=-1.04; 95%CI:-1.62,-0.93) and > 7-10 mg/kg/day (ß=-1.36; 95%CI:-1.56,-1.02) were associated with a lower daily-WG. However, during 29-42DOL, this association was present only for > 7-10 mg/kg/day (ß=-1.54; 95%CI:-1.66,-1.42). The GA ≤ 27weeks (ß=-1.03 95%CI:-1.24, -0.88) was associated with lower daily-WG only during 15-28DOL. During both periods of therapy, higher cumulative-caffeine dose and presence of culture proven sepsis, tachypnea, hyponatremia, and feeding intolerance were significantly associated with lower daily-WG. Conversely, daily kcal intake was found to be linked with an increase in daily-WG in both periods. CONCLUSION: In this study cohort exposure to higher caffeine daily and cumulative doses is associated with lower postnatal daily-WG in PTNs than standard-daily doses, which may be due to its catabolic effects and CC-APSEs.

MBBS admission criteria as predictor of academic performance in a medical college of Pakistan.

Objective: To determine the relationship between scores obtained by students in assessments considered as admission criteria (cognitive and non-cognitive) with their academic performance in medical college. Method: This correlational study used the data of students who got admission in Shalamar Medical and Dental College (SMDC) in 2015. Spearman correlation and Multiple regression tests were carried out to determine the relationship between admission criteria (Matric, FSC, MDCAT and MMI) and academic performance in medical college (pre-clinical and clinical years). Results: There was significant positive correlation between scores obtained in MDCAT and pre-clinical years. When combined, MDCAT and MMI scores showed a significant positive correlation with scores obtained by students in clinical years. Scores obtained by students in pre-clinical years strongly correlated with their performance in clinical years. While scores obtained by students in FSC showed negative correlation with clinical year scores, significantly. Conclusion: It is concluded that the tools used for admission criteria should include both cognitive and non-cognitive elements. MDCAT is a good predictor of academic performance in pre-clinical years however it can only predict performance in clinical years when combined with MMI since MMI assesses the non-cognitive attributes (communication, empathy, ethics etc.) required in those years. FSC should not be given weightage as admission criteria owing to a lot of variability in the exams and scoring of different academic boards of the country.

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.

Diagnostic accuracy of C-reactive protein to rule out infectious complications following hip fracture surgery.

Background and Objective: Knowledge of the C-reactive protein trend and deviation from the expected value may give an early indication of a possible postoperative infection. According to previous studies, CRP appears to be a more sensitive and specific marker of postoperative infections than ESR and white cell count. This study was conducted to determine the diagnostic accuracy of C-reactive protein to rule out surgical site infection in patients undergoing hip fracture surgery. Methods: This cross-sectional study was conducted at The Indus Hospital and Health Network, Karachi from July 1, 2018 to February 24, 2020. All operative hip fracture patients aged 11-90 years were included. CRP was done on admission, days 3, 14 and 28. Wound assessment was done using the criteria of the Center of Disease Control and prevention on postoperative days 3, 14 and 28. Data was analyzed using STATA version 16. Results: Out of 152 patients, 11(7.2%) developed infection. One patient (0.7%) presented with the infection on day three post-surgery, eight (5.3%) and two (1.3%) patients on days 14 and 28 respectively. CRP levels at admission had poor diagnostic accuracy for diagnosing infection at 14th and 28th day post-surgery respectively (AUC=0.490 and 0.447). CRP levels measured on post-op Day-3 (cutoff value 230mg/dl) had good diagnostic accuracy for diagnosing infection at 14th and 28th day post-surgery respectively (AUC=0.819 and 0.818). Conclusion: CRP level at post-operative day three is a sensitive indicator of infection after hip fracture surgery.

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.

The frequency of vitamin D deficiency in chronic kidney disease and its relation with baseline mineral bone markers.

OBJECTIVE: To assess the frequency of Vitamin D deficiency in chronic kidney disease and its association with baseline mineral bone markers in patients visiting nephrology clinics. METHODS: The observational study was conducted at the Indus Hospital, Karachi, from January 2017 to January 2018, and comprised patients of either gender aged >16 years diagnosed with chronic kidney disease stage I-V. The patients were divided into two groups on the basis of severity of vitamin D deficiency. Severe vitamin D deficiency was defined as <10ng/ml, and moderate deficiency ad 10- 25ng/ml. Data was analysed using SPSS 21. RESULTS: Of the 267 patients, 146(54.7%) were males and 189(70.8%) had vitamin D deficiency. Vitamin D-deficient patients were younger than those with normal levels (p=0.044). Serum creatinine was raised in the deficient patients compared to those with normal vitamin D level (p=0.042). Females and currently employed patients were at a higher risk of having vitamin D deficiency (p=0.048, 0.009). There was no si gn ific ant as s ociation between disease stage a nd vitamin D defic ienc y ( p= 0.311). CONCLUSIONS: Vitamin D deficiency was found in a significant proportion of chronic kidney disease patients irrespective of the disease stage. Females, currently employed and young patients were more prone to having vitamin D deficiency.

Frequency, clinical characteristics, risks, and outcomes of Paradoxical upgrading reactions during anti-tuberculosis treatment in tuberculous lymphadenitis.

OBJECTIVES: To investigate the clinical characteristics, risks and outcomes of Paradoxical upgrading reactions (PUR) during anti-tuberculosis treatment (ATT) in superficial tuberculous lymphadenitis (TBLA). METHODS: In this nested case-control study, all patients diagnosed with TBLA based on combinations of histopathology, acid-fast bacilli (AFB) microscopy, AFB culture, and GeneXpert, between February 2013 and April 2016, were enrolled. Standard ATT was given. Demographics, clinical characteristics, occurrence of PUR and outcome were recorded. RESULTS: TBLA was diagnosed and treated in 189 patients. PUR developed in 33 (17%), of which 77% developed new inflamed glands, 20.6% had increased size and inflammation of pre-existing glands and 5.9% had superficial chest wall abscesses requiring aspiration. All responded to regular NSAIDs except one, where a steroid course was effective. No change in dose or duration of ATT was required. Presence of anorexia (OR; 95%CI: 2.6; 1.003-6.74), bilateral extensive lymphadenopathy (OR; 95%CI: 2.9; 1.1-7.5) and lymph node specimen positive for AFB (OR; 95%CI: 3.2; 1.04-10.1) were significantly associated with PUR. CONCLUSION: PUR is common in TBLA. It responded to NSAIDS and does not need any modification in ATT.

Malaria and the climate in Karachi: An eight year review.

BACKGROUND AND OBJECTIVE: Malaria is an arthropod-borne infectious disease transmitted by the mosquito Anopheles and claims millions of lives globally every year. Reasons for failure to eradicate this disease are multifactorial. The seasonality of the malaria is principally determined by climatic factors conducive for breeding of the vector. We aimed to study the relationship between climatic variability and the seasonality of malaria over an eight-year duration. METHODS: This was a retrospective medical chart review of 8,844 confirmed cases of malaria which presented to The Indus Hospital, Karachi from January 2008 to November 2015. Cases were plotted against meteorological data for Karachi to elicit monthly variation. RESULTS: A secular incline and seasonality in malaria cases over the duration of eight years was seen. More cases were reported in the summer, rainy season compared with the other three seasons in each year. There was significant association with specific climate variables such as temperature, moisture, and humidity. CONCLUSION: There is a marked seasonal variation of malaria in Karachi, influenced by various environmental factors. Identification of the 'the concentrated period' of malaria can be helpful for policymakers to deploy malaria control interventions.

High proportion of overt diabetes mellitus in pregnancy and missed opportunity for early detection of diabetes at a tertiary care centre in Pakistan.

OBJECTIVES: To determine the frequency of diabetes in pregnancy (DIP), namely pre-gestational, gestational (GDM) and overt diabetes mellitus (DM) in women registered for delivery. METHODS: A retrospective chart review of antenatal women registered between January 01 to August 31, 2017 was performed. Gestational age, diagnosis of DIP, glucose levels at diagnosis and other relevant data was extracted. The effect of various fasting blood glucose (FBG) thresholds for diagnosis of DIP was assessed. RESULTS: DIP was diagnosed in 21.8% women (pre-gestational: 2%, GDM: 81.2%, overt: DM: 16.8%). In early registrants, 30.2% were detected through screening. However, 55.3% of women registered late. Women with pre-gestational DM were older, had more miscarriages, and greater personal and family history of diabetes versus GDM and overt DM. Raising the diagnostic threshold of FBG from 92 mg/dl to 95 mg/dl missed three women (0.1%) and to 105 mg/dl, missed six women (0.2%). CONCLUSION: We observed a high proportion of overt DM. In early registrants, almost one third of DIP was diagnosed in the first half of pregnancy, an opportunity missed in late registrants. Altering diagnostic thresholds of DIP affected only a small proportion of women.

Retinoblastoma Presentation and Survival: A four-year analysis from a tertiary care hospital.

OBJECTIVE: To study the clinical presentation, treatment, and outcome of Retinoblastoma (Rb) in a tertiary care hospital of Pakistan. METHODS: A retrospective study was conducted in the Department of Pediatric Hematology Oncology, The Indus Hospital (TIH), Karachi from 1st June 2013 to 30th June 2017. Data including patients' demography, clinical symptoms and duration, laterality, extent of the tumor, type of treatment, relapse, and final outcome were extracted and evaluated with respect to progression and survival. RESULTS: A total of 93 patients were included; 34.4% were boys. The median age at presentation was 30 months. Leukocoria was the commonest symptom (61.3%), followed by proptosis (37.6%). Unilateral disease was seen in 59.1%, extraocular tumors in 43.5% and metastasis in 28.1%. Enucleation was performed on 46.2%, chemotherapy given to 80.6% and external beam radiation therapy to 29.3% patients. CONCLUSION: Delayed presentation, recurrent disease, extraocular disease and metastasis on presentation were factors affecting outcome in our cohort. Awareness about the early warning signs and symptoms in both public and health professionals for early recognition and timely management are mandatory to decrease morbidity and mortality.

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.

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's 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.

Angina bullous haemorrhagica: Case report and review of literature.

Angina Bullosa Haemorrhagica (ABH) is a benign lesion of the oral cavity categorized by sudden onset of single or multiple blood filled lesions that burst leaving an ulcer that usually heals in 7-10 days without leaving a scar. We report a case of ABH diagnosed on the basis of history, clinical examination and blood, renal and liver function tests. The case findings and its management is discussed. Literature of the cases presented in the last 5 years was searched from Google Scholar and Pubmed. The review was summarized in a tabulated form.

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's 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 >50×10/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.

Perception about braces in parents of children with clubfoot.

OBJECTIVE: To access the acceptability of Steenbeek brace by children undergoing clubfoot correction and their parents to ensure long-term compliance. METHODS: The cross-sectional study was conducted at the Indus Hospital, Karachi from October 2013 to March 2014. A trained researcher interviewed the person primarily responsible for bracing the child using a pre-coded questionnaire. Modified Orthotics Prosthetics User Survey for satisfaction with either the Mitchell brace of the Steenbeek brace was used. It included 11 questions in the Parent Bracing Satisfaction Survey. SPSS 21 was used for statistical analysis. RESULTS: Interviews were completed with 110 primary caregivers among whom 90(81.8%) were mothers. Overall, 32(29.1%) children were using the Mitchell brace, 30(27.3%) the Steenbeek brace, 46(41.8%) had shifted from Mitchell to Steenbeek brace, and 2(1.8%) had shifted from Steenbeek to Mitchell brace. Median duration of current brace usage was 4 and 3.5 months for Steenbeek and Mitchell braces respectively. The mean age of the child was 1.4 ±0.7 years, and the mean of 4-point Likerts cale score of parent bracing satisfaction was 28.7±2.2 in children on the Mitchell brace versus 28.5±1.9 for those on Steenbeek brace (p=0.505). Overall, 82(74.5%) parents had favourable attitude towards braces in general, but there were no significant differences in the items except "brace is easy to put on" (p=0.040) and "durability between Mitchell and Steenbeek groups" (p=0.017). CONCLUSIONS: There were no differences in satisfaction levels between the two types of brace users.

Evaluating an immunization carpool service for women in rural areas for facilitating routine childhood immunizations in Pakistan -a feasibility study on acceptability, demand, and implementation.

Introduction: Poor accessibility of immunization services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunization coverage in rural areas. We assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunization in a rural setting in Pakistan and evaluated its preliminary impact on immunization coverage and timeliness among children. Methods: We conducted a feasibility study in four selected immunization facilities in Shikarpur District, Sindh. A local transport vehicle was hired and branded as an immunization carpool service. Women having un- or under-immunized children aged ≤2 years were invited to visit immunization facilities using carpool vehicles. Information on demographic indicators and service experience was collected. Child immunization details were extracted using the government's provincial electronic immunization registry to estimate immunization coverage and timeliness. Results: Between January and October 2020, six immunization carpool vehicles provided uninterrupted service and transported 2422 women-child pairs, completing 4691 immunization visits. Majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). Preliminary estimates reported an increase in immunization coverage and timeliness across antigens among participating children compared to non-participating children, with significant increase in proportion for BCG coverage (38.1%; p < 0.001, CI: 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%). Conclusion: A women-only immunization carpool service implemented within a rural setting is feasible and highly acceptable. Key factors contributing to the model's success include increased mobility and independence of women, cost-savings, and a culturally and contextually appropriate mechanism of transport embedded within the local setting. Increased accessibility to health services also contributed to improved immunization coverage and timeliness among children.

Barriers and Facilitators for Female Healthcare Professionals to Be Leaders in Pakistan: A Qualitative Exploratory Study.

Purpose: Despite being in high numbers in medical colleges, only a small proportion of women join the workforce and even fewer reach leadership positions in Pakistan. Organizations like United Nations and Women Global Health are working towards closing the gender gap. The study aims to explore the enablers and barriers for women in healthcare leadership and to explore the strategies to promote women in leadership positions in Pakistan's specific societal culture. Methods: In this qualitative exploratory study, semi-structured interviews of 16 women holding leadership positions in the health-care profession, ie, medical and dental (basic or clinical sciences) were included. The data were collected until saturation was achieved. The data were analyzed in MS Excel. Deductive and Inductive thematic analysis was done. Results: Thirty-eight codes were generated that were combined in the form of categories. The major themes that emerged from the data were: elevating factors, the shackles holding them back, let us bring them up and implicit bias. Elevating factors were intrinsic motivation and exceptional qualifications, while the shackles were related to gender bias, male insecurities, and lack of political background. It was noteworthy that differences in gender roles were highly defined by culture and religion. Conclusion: There is a need to change the perception of South Asian society and redefine gender roles through media and individual attempts. Women must take charge of their choices and believe in themselves. The institutional policies to help promote gender equality would be mentorship programs for new faculty, gender-responsive training for everyone, equal opportunities for all, and maintaining gender diversity on all committees.

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.

Immunization Gender Inequity in Pakistan: An Analysis of 6.2 Million Children Born from 2019 to 2022 and Enrolled in the Sindh Electronic Immunization Registry.

Gender-based inequities in immunization impede the universal coverage of childhood vaccines. Leveraging data from the Government of Sindh's Electronic Immunization Registry (SEIR), we estimated inequalities in immunization for males and females from the 2019-2022 birth cohorts in Pakistan. We computed male-to-female (M:F) and gender inequality ratios (GIR) Tfor enrollment, vaccine coverage, and timeliness. We also explored the inequities by maternal literacy, geographic location, mode of vaccination delivery, and gender of vaccinators. Between 1 January 2019, and 31 December 2022, 6,235,305 children were enrolled in the SEIR, 52.2% males and 47.8% females. We observed a median M:F ratio of 1.03 at enrollment and at Penta-1, Penta-3, and Measles-1 vaccinations, indicating more males were enrolled in the immunization system than females. Once enrolled, a median GIR of 1.00 indicated similar coverage for females and males over time; however, females experienced a delay in their vaccination timeliness. Low maternal education; residing in remote-rural, rural, and slum regions; and receiving vaccines at fixed sites, as compared to outreach, were associated with fewer females being vaccinated, as compared to males. Our findings suggeste the need to tailor and implement gender-sensitive policies and strategies for improving equity in immunization, especially in vulnerable geographies with persistently high inequalities.

Using geographic information system to track children and optimize immunization coverage and equity in Karachi, Pakistan.

BACKGROUND: Despite the potential of geospatial technologies to track and monitor coverage, they are underutilized for guiding immunization program strategy and implementation, especially in low-and-middle-income countries. We conducted geospatial analysis to explore the geographic and temporal trends of immunization coverage, and examined the pattern of immunization service access (outreach and facility based) by children. METHODOLOGY: We extracted data to analyze coverage rates across different dimensions (by enrolment year, birth year and vaccination year) from 2018 till 2020 in Karachi, Pakistan using the Sindh Electronic Immunization Registry (SEIR). We conducted geospatial analysis to assess variation in coverage rates of BCG, Pentavalent (Penta)-1, Penta-3, and Measles-1 vaccines using Government targets. We also analyzed the proportion of children receiving their routine vaccinations at fixed centers and outreach and examined whether children received vaccinations at the same or multiple immunization centers. RESULTS: A total of 1,298,555 children were born, enrolled or vaccinated from 2018 till 2020. At the district level, analysis by enrollment and birth year showed coverage increased between 2018 and 2019 and declined in 2020, while analysis by vaccination year showed consistent increase in coverage. However, micro-geographic analysis revealed pockets where coverage persistently declined. Notably 27/168, 39/168 and 3/156 Union councils showed consistently declining coverage when analyzing by enrollment, birth and vaccination year respectively. More than half (52.2%, 678,280/1,298,555) of the children received all their vaccinations exclusively through fixed centers and, 71.7% (499,391/696,701) received all vaccinations from the same centers. CONCLUSION: Despite overall improving vaccination coverage between 2018 and 2020, certain geographic areas have consistently declining coverage rates, which is detrimental for equity. Making immunization inequities visible through geospatial analysis is the first step to ensure resources are allocated optimally. Our study provides impetus for immunization programs to develop and invest in geospatial technologies, harnessing its potential for improved coverage and equity.