Effectiveness of locally produced ready-to-use supplementary foods on the prevention of stunting in children aged 6-23 months: a community-based trial from Pakistan.

Undernutrition is a major public health problem in developing countries. Around 40·2 % of children are stunted in Pakistan. This longitudinal study aimed to assess the effectiveness of locally produced ready-to-use supplementary foods in the prevention of stunting by detecting change in of children in intervention v. control arm against the 2006 WHO growth reference. A community-based non-randomised cluster-controlled trial was conducted from January 2018 to December 2020 in the district of Kurram, Khyber Pakhtunkhwa, Pakistan. A total of 80 clusters (each cluster comprising ≈ 250-300 households) were defined in the catchment population of twelve health facilities. Children aged 6-18 months were recruited n 1680. The intervention included a daily ration of 50 g - locally produced ready-to-use-supplementary food (Wawa-Mum). The main outcome of this study was a change in length for age z-score (LAZ) v. WHO growth standards. Comparison between the interventions was by t test and ANOVA. Cox proportional hazard models were used to assess the association between stunting occurrence and the utilisation of locally produced supplement. Out of the total 1680, fifty-one out of the total 1680, 51·1 out of the total 1680 and 51·1 % (n 859) were male. Mean age 13·9 months (sd + 859) were male. Mean age 13·9 months (sd + -4·4). At baseline, 36·9 % (n 618) were stunted. In the intervention group, mean LAZ score significantly increased from -1·13(2·2 sd) at baseline to -0·93(1·8 sd) at 6-month follow-up (P value 0·01) compared with the control group. The incidence rate of stunting in the intervention arm was 1·3 v. 3·4 per person year in the control arm. The control group had a significantly increased likelihood of stunting (Hazard Ratio (HR) 1·7, 95 % CI 1·46, 2·05, P value < 0·001) v. the intervention group. Locally produced ready-to-use supplementary food is an effective intervention for reducing stunting in children below 2 years of age. This can be provided as part of a malnutrition prevention package to overcome the alarming rates of stunting in Pakistan.

How does postgraduate diploma in Family Medicine impact on primary care doctors?

BACKGROUND: Over the last decade, the emphasis on improving the education and training of family physicians has increased. World Health Organization has also emphasized the importance of a trained primary care workforce. In 2017, Khyber Medical University (KMU) Peshawar initiated a one-year Postgraduate Diploma in Family Medicine for doctors working in primary care, to upgrade their skills and knowledge as Family Physicians. To justify the allocation of resources, there is a need for research on the impact of such programs. This study explores the impact of Diploma in Family Medicine (DFM) on primary care doctors in Khyber Pakhtunkhwa. It also identifies the barriers associated with learning and its translation to practice. METHODS: A mixed-method explanatory study was conducted from February 2019-2020. Forty-five graduates from the DFM program at KMU were invited to participate in this study. The quantitative data was collected through questionnaires (n=30) and the results were then explained further through qualitative focus group interviews (n=24). Descriptive statistics were calculated for the quantitative data and thematic analysis was performed for the qualitative data. RESULTS: The respondents (n=30/45) were satisfied from the course content and delivery. They agreed that the course is useful (93.3%), relevant to their learning needs (86.7%) and they were able apply it to their clinical practice (100%). The qualitative findings also corroborated that the course improved both the clinical and consultation skills of the participants. The learning environment encouraged them to identify their learning needs and attain new competencies. They reported being more patient-centered and evidence-based, which increased patients' satisfaction. The program also resulted in increased career opportunities and other monetary benefits. Despite the blended nature of the program, the participants found it challenging to balance training with the provision of services. CONCLUSION: One-year Postgraduate Diploma in Family Medicine is focused, practical and relevant to the learning needs of primary healthcare physicians. The policymakers should consider provision of such training opportunities in both public and private-sector. Future research should explore the long-term impact of such programs on healthcare outcomes.

Early Intervention in Psychosis and Management of First Episode Psychosis in Low- and Lower-Middle-Income Countries: A Systematic Review.

BACKGROUND AND HYPOTHESIS: People with first-episode psychosis (FEP) in low- and lower-middle-income countries (LMIC) experience delays in receiving treatment, resulting in poorer outcomes and higher mortality. There is robust evidence for effective and cost-effective early intervention in psychosis (EIP) services for FEP, but the evidence for EIP in LMIC has not been reviewed. We aim to review the evidence on early intervention for the management of FEP in LMIC. STUDY DESIGN: We searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) to identify studies describing EIP services and interventions to treat FEP in LMIC published from 1980 onward. The bibliography of relevant articles was hand-searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. STUDY RESULTS: The search strategy produced 5074 records; we included 18 studies with 2294 participants from 6 LMIC countries. Thirteen studies (1553 participants) described different approaches for EIP. Pharmacological intervention studies (n = 4; 433 participants) found a high prevalence of metabolic syndrome among FEP receiving antipsychotics (P ≤ .005). One study found a better quality of life in patients using injectables compared to oral antipsychotics (P = .023). Among the non-pharmacological interventions (n = 3; 308 participants), SMS reminders improved treatment engagement (OR = 1.80, CI = 1.02-3.19). The methodological quality of studies evidence was relatively low. CONCLUSIONS: The limited evidence showed that EIP can be provided in LMIC with adaptations for cultural factors and limited resources. Adaptations included collaboration with traditional healers, involving nonspecialist healthcare professionals, using mobile technology, considering the optimum use of long-acting antipsychotics, and monitoring antipsychotic side effects.

Traditional healers working with primary care and mental health for early intervention in psychosis in young persons: protocol for the feasibility cluster randomised controlled trial.

OBJECTIVES: In low/middle-income countries (LMICs), more than half of patients with first-episode psychosis initially seek treatment from traditional and religious healers as their first care. This contributes to an excessively long duration of untreated psychosis (DUP). There is a need for culturally appropriate interventions to involve traditional and spiritual healers to work collaboratively with primary care practitioners and psychiatrists through task-shifting for early detection, referral and treatment of first episode of psychosis. METHODS: To prevent the consequences of long DUP in adolescents in LMICs, we aim to develop and pilot test a culturally appropriate and context-bespoke intervention. Traditional HEalers working with primary care and mental Health for early interventiOn in Psychosis in young pErsons (THE HOPE) will be developed using ethnographic and qualitative methods with traditional healers and caregivers. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. Ninety-three union councils in district Peshawar, Pakistan will be randomised and allocated using a 1:1 ratio to either intervention arm (THE HOPE) or enhanced treatment as usual and stratified by urban/rural setting. Data on feasibility outcomes will be collected at baseline and follow-up. Patients, carers, clinicians and policymakers will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Keele University Ethical Review Panel (ref: MH210177), Khyber Medical University Ethical Review Board (ref: DIR/KMU-EB/IG/001005) and National Bioethics Committee Pakistan (ref no. 4-87/NBC-840/22/621). The results of THE HOPE feasibility trial will be reported in peer-reviewed journals and academic conferences and disseminated to local stakeholders and policymakers. TRIAL REGISTRATION NUMBER: ISRCTN75347421.

Triple Assessment of Breast Lump: Should We Perform Core Biopsy for Every Patient?

Introduction The triple assessment for a lump in the breast is standard practice and the robustness of assessment towards the diagnosis of breast cancer is crucial. The combination of the modalities, physical examination, imaging (mammogram and ultrasound), and fine-needle aspiration cytology (FNAC) is more accurate than any modality alone. Aim To examine the combined and individual predictive values of physical examination (P), mammography (M), ultrasound (U), FNAC (C), with core biopsy (B) - triple assessment in the diagnosis of breast cancer. Methods To obtain the results of physical examination (P), mammography (M), ultrasound (U), FNAC (C), and core biopsy (B), we examined the records of 124 breast cancer patients seen between April 1, 2009, and March 30, 2010. To assess the diagnostic potential of the combination of the modalities (P, U, and M), we considered all cases with a score of 4 (probably malignant) and 5 (malignant) as positive for malignancy. All cases with a score of 3 (equivocal), 2 (benign), and 1 (normal) were considered negative for malignancy. For FNAC, a score of 1 (insufficient sample), 2 (benign), and 3 (atypia/probably benign) were considered. All the patients were diagnosed with breast cancer on excision biopsy. Among 124 patients, 12 were excluded, as they were unfit for intervention. Results The accuracy of physical examination (P) as confirmed by core biopsy (B) is dependent on the experience of the surgeon. It has limitations in younger women and smaller lesions. In our study, P has a positive predictive value (PPV) of 58.9% when compared with surgical biopsy, which is comparable with other studies. Our results showed PPV 66.1% and after an ultrasound scan, the overall radiological grading (M & U) gives a PPV of 81.3%, reflecting the important role of ultrasound scans. Our results showed the sensitivity of FNAC to be 73.2%. Core biopsy was diagnostic in 107 (95.5%) patients, making it a reliable tool. Our results confirmed that a combination of the modalities (P, M, U, R, FNAC) is more accurate than any modality alone. Conclusion When all the three modalities are positive for a diagnosis of malignant breast disease, surgical biopsy confirms the breast cancer diagnosis with a PPV of 100% and a sensitivity of 95.5%.

Comparison of 'Excision and Primary Repair' with 'Bascom's Technique' in the Surgical Treatment of Pilonidal Sinus.

Introduction The management of the chronic pilonidal disease is variable and the principles of treatment are aimed to eradicate the sinus tract, promote wound healing, prevent disease recurrence, and improve the quality of life of the patient. This study aims to compare the effectiveness of excision and primary closure, and Bascom's technique in the management of pilonidal sinus disease. Methods  The study was performed at a tertiary hospital from April to October 2011. All patients with chronic pilonidal sinus were included in the study (n=60) and randomly allocated into Group A - undergoing excision and primary closure (n=30) and Group B - undergoing Bascom's repair. Comparative outcomes of interest were duration of hospital admission, post-operative pain, wound infection, wound-healing and disease recurrence.  Results The mean age of presentation was 24.18±5.6 years. A higher number of patients in Group A were discharged within 24 hours compared to Group B (p = 0.001). Group B had significantly less post-operative pain by the first postoperative week (p = 0.049). Group B had lower infection rates with clean wounds observed in 28 (93.3%) patients compared to 23 (76.7%) in Group A by the first postoperative week (p = 0.07). Recurrence rate during 12-week follow-up was observed in one (3.3%) patient in Group B, and five (16.7%) in Group A (p= 0.085). Conclusions Patients who underwent Bascom's operation had less postoperative pain, lower infection rates and disease recurrence, and better wound healing. Therefore, in our patient cohort, we conclude Bascom's repair appears to be superior to primary excision and repair in reducing patient morbidity.

Perception Of Health Professionals Towards The Scope Of Family Medicine In The Healthcare System Of Pakistan.

BACKGROUND: Background: Primary health care is the backbone of comprehensive healthcare systems, and family physicians complement horizontal health coverage. In the developed world family medicine is integral to new doctors' training but, in the developing world, there are hurdles, e.g., poorly targeted financing, lack of skills and resources, and little health professionals' interest in the specialty. METHODS: This study determined perceptions of undergraduate and postgraduate medical trainees and healthcare professionals in Pakistan about family medicine. Participants' perceptions were examined via a selfadministered pre-structured questionnaire about family medicine in developing countries before and after a targeted seminar. Epi Info software (v.7) was used for statistical analysis. The p-value <0.05 was considered statistically significant. RESULTS: One hundred & eight questionnaires were returned postseminar demonstrating raised participant awareness of family medicine, with the majority (postgraduate 90.00% and undergraduate 90.91%) believing that health departments should create family medicine specialist posts to encourage students and post-graduate trainees. Similarly, 89.77% undergraduates and 95.00% postgraduates believed that comprehensive family medicine in primary health could be a solution to improve health care in Pakistan. Of note, when asked pre-seminar "do you feel you would consider family medicine as career speciality?", 42% undergraduates replied yes; when asked the same question post-seminar 63% of undergraduates and 90% of postgraduates replied yes. CONCLUSIONS: Introducing family medicine as a subject in medical colleges will create awareness and interest towards this speciality; until then, awareness lectures and seminars by trained family physicians will help bridge the gap towards encouraging students about its benefits.