Extensively drug-resistant Salmonella Typhi leading to relapsed urinary tract infection: A case report.

Salmonella enterica serotype Typhi (S Typhi) associated urinary tract infections are exceedingly rare, accounting for less than 1% of cases. Such infections have known to occur in immune-compromised or individuals with urogenital structural abnormalities. With the emergence of extensively drug resistant S Typhi strains in Pakistan, the management of its various unique presentations poses therapeutic challenges. We report the first documented case of a 74 years old male patient presenting with relapsed urinary tract infection secondary to extensively drug resistant S Typhi.

A curious case of expanded dengue syndrome.

Dengue fever (DF) primarily presents with fever, headache, malaise, bleeding manifestations and haemoconcentration. World Health Organization (WHO) classifies DF according to levels of severity: (a) without warning signs; (b) with warning signs, such as abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing haematocrit and thrombocytopenia; and (c) severe dengue with severe plasma leakage, severe bleeding or organ failure. Atypical clinical presentations of DF are defined as expanded dengue syndrome: this includes renal, cardiac, hepatic or cerebral damage. We report such a severe case where a young man developed acute kidney injury, acute fulminant liver failure and acute pancreatitis secondary to DF, but recovered.

Characteristics of mobile phone access and usage among caregivers in Pakistan - A mHealth survey of urban and rural population.

INTRODUCTION: Globally mobile ownership and access is becoming very common, and breakthroughs in mobile technology have shaped digital communication, with 7 billion mobile phone users globally. Developing countries account for 80% of newly purchased mobile phone devices with majority of such countries having low Routine Immunization coverage and a high risk of vaccine preventable diseases. The use of mobile phones provides a tremendous potential for public health involvement. OBJECTIVE: The aim of this study is to assess the acceptability and usability of mobile phones among infant caregivers in a LMIC setup and to explore the role of mHealth to improve immunization uptake and coverage. METHODS: This is a cross-sectional survey exploring the regional differences in mobile phone ownership, usability and preferences, along with level of trust with others while sharing a mobile phone. The study was conducted with caregivers of infants in an urban and rural sites of Pakistan. RESULTS: A total of 4472 households were approached, of which 3337 participants were eligible for the study (74.61 %). The reasons for not participating in the study (n = 1135) included (i) household locked or refusal to participate for 594 families (52%), (ii) child older than 14 days of life in 409 cases (36%), (iii) 80 (7%) families did not have access to a functional mobile phone, (iv) 36 (3%)families did not provide a mobile phone number, and (v) 14 (1%) could not stay within the HDSS for 6 months. Access to mobile phone with SMS features was considerably high at both sites: 99.1% in Matiari (rural site) and 96.7% in Karachi (urban). In Matiari 96.6% of the respondents reported having daily access to the phone, contrasting with only 51.4% in Karachi. In Karachi, the predominant spoken language was Urdu, whereas majority of the respondents in Matiari spoke Sindhi (34.6% vs. 70.9%). CONCLUSION: Our study indicates high access to mobile phone in both urban and rural setup, However access to smart phone is still limited, urban and rural setup. Further, the acceptance of overall health- and barrier-based child immunization messages through mobile phone were quite high in both settings. Lastly automated calls were preferred over SMS due to literacy and local settings. This bears important implications for improving child immunization uptake through mobile phones in developing regions such as Pakistan.

Effect of Mobile Phone Text Message Reminders on Routine Immunization Uptake in Pakistan: Randomized Controlled Trial.

BACKGROUND: Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide. OBJECTIVE: The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan. METHODS: This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses. RESULTS: Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant. CONCLUSIONS: Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs). TRIAL REGISTRATION: ClinicalTrials.gov NCT01859546; https://clinicaltrials.gov/ct2/show/NCT01859546 (Archived by WebCite at http://www.webcitation.org/6xFr57AOc).

Assessing acceptability of hypertensive/diabetic patients towards mobile health based behavioral interventions in Pakistan: A pilot study.

INTRODUCTION: Diabetes and hypertension are prevalent chronic diseases among the general population of Pakistan with an exponential progress expected over the upcoming years. Mobile Health services can be an efficient method of helping curtail this rise and improve quality of life of such patients as proven in developed countries. We aim to assess the acceptability of using Mobile Health services among diabetic and hypertensive patients in Pakistan. METHODS: A total of 100 patients were approached in a large tertiary care Government Hospital of Karachi, Pakistan, using a nonprobability convenient sampling technique. Co-authors conducted an interview based sampling of a modified questionnaire to each participant after consent. All data was recorded and analyzed on SPSS 16. RESULTS: A total of 100 patients participated in our study with 66 (66%) males and 34 (34%) females having a mean prevalence age of 54.27. All the 100 participants had easy access to cell phones with 88% participants (88/100) stating that they would be willing to participate in Mobile Health based interventions. A statistically significant number (p=0.014) of them preferred receiving phone calls (85.2%) rather than SMS (14.8%) reminders for these interventions. 85% of the participants even agreed to participate in such intervention on cash incentives. CONCLUSION: The use of phone call reminders or SMS reminders seems like an acceptable and favorable option among hypertensive and diabetic patients. This can greatly improve their self-management and help curtail this rise in the future.

Assessing Acceptability of Short Message Service Based Interventions towards Becoming Future Voluntary Blood Donors.

All blood bank services, especially those of developing countries, face a major shortfall of blood donations due to lack of voluntary blood donors. Our study aims to evaluate the acceptability of Short Message Service based interventions towards becoming voluntary blood donors among medical university students of Karachi, Pakistan. Methods. A total of 350 medical students were approached in medical universities of Karachi, Pakistan, using a nonprobability convenient sampling technique. Data collectors administered a self-made questionnaire to each participant using an interview based format. All data was recorded and analyzed on SPSS 16. Results. 350 participants, having a mean age of 21.47 ± 1.36, were included in our study with 30.6% (107/350) being males and 69.4% (243/350) being females. 93.4% (327/350) of participants agreed that donating blood was healthy, but only 26% had donated blood in the past with 79.1% donating voluntarily. 65.7% (230/350) of the participants agreed to take part in Short Message Service based behavioral interventions to become voluntary blood donors with 69.7% (244/350) also agreeing that Short Message Service reminders will promote them to donate blood more often. Conclusion. With university students willing to become voluntary blood donors, Pakistani blood banks can carry out Short Message Service based interventions to encourage them to donate blood.

Using skeletonised grafts for coronary artery bypass grafting.

Coronary artery bypass graft surgery relieves angina symptoms and reduces mortality among ischaemic heart disease patients. It remains the gold standard for the treatment of multi-vessel and left main coronary artery disease. It is a well-known fact that internal mammary artery conduits have excellent and long-lasting patency when used for coronary artery bypass grafting. Its supremacy is largely because it prevents atherosclerosis. The old-style internal mammary artery bypass grafting, classically known as pedicle grafting, includes a circular rim of tissue around the graft. Bilateral pedicled internal mammary arteries, especially among diabetic patients, have been reported to cause complications in the sternum like sternal osteomyelitis. In many studies it has been reported that dissection of pedicled internal mammary artery can lead to sternal devascularisation which can lead to higher incidence of infections. Considering the higher incidence of deep sternal infections in patients with double pedicled arterial grafts, dissection of internal mammary artery in skeletonised manner was proposed. In this review, we outline the advantages of skeletonised grafting with respect to incidence of sternal infection, patency rates, blood flow, post-coronary artery bypass graft pain and the length of the graft.

Knowledge and practices of barbers regarding HIV transmission in Karachi: a cross-sectional study.

A barber shop is a potential place for non-sexual transmission of deadly blood borne diseases such as acquired immuno-deficient syndrome. Few researches have been conducted to assess the knowledge of barbers regarding human immunodeficiency virus (HIV) transmission in Pakistan. With majority of the population visiting roadside saloons, it is imperative to have local data in this regard. The objective of this study was to investigate the knowledge and practices of barbers with reference to razor use and steps taken to sterilize their instruments. A total of 300 barber saloons were conveniently selected for this cross-sectional study during a time period of 5 months from May 2012 till September 2012. The shops were categorized into three groups: big saloons, small saloons and roadside saloons based on the inclusion criteria. One barber was randomly selected as a representative from each saloon. Data collection from each barber shop was carried out by an interviewer using a pre-coded questionnaire. Majority of the barbers had low school education. Awareness regarding sharing of blades as a route of HIV transmission was known by 90 % (n = 90) of big saloon barbers with awareness decreasing in small (n = 55) and roadside saloon barbers (n = 27). Only 60.3 % (n = 181) of the barbers used new blades between customers. In comparison to big saloon barbers, the majority (n = 53) of roadside saloon barbers used tap water for cleaning purposes. Only 40 % of the roadside barbers used antiseptic after shaving. The results of our study indicate that roadside saloon barbers, to whom majority of Pakistani population visit, have inadequate awareness regarding HIV transmission. Their poor barbering practices were mainly due to their low education. This potentiates a great risk for aggravating the HIV endemic in Pakistan.

Role of vitamin K2 in preventing the recurrence of hepatocellular carcinoma after curative treatment: a meta-analysis of randomized controlled trials.

BACKGROUND: Hepatocellular cancer is notorious for recurrence even after curative therapy. High recurrence determines the long term prognosis of the patients. Vitamin K2 has been tested in trials for its effect on prevention of recurrence and improving survival. The results are inconclusive from individual trials and in our knowledge no systematic review which entirely focuses on Vitamin K2 as a chemo preventive agent is available to date. This review is an attempt to pool all the existing trials together and update the existing knowledge on the topic. METHODS: Medline, Embase and Cochrane Register of Controlled trials were searched for randomized controlled trials where vitamin K2 or its analogues, in any dosage were compared to placebo or No vitamin K2, for participants of any age or sex. Reference lists and abstracts of conference proceedings were searched by hand. Additional papers were identified by a manual search of the references from the key articles. Attempt was made to contact the authors of primary studies for missing data and with the experts in the field.Trials were assessed for inclusion by two independent reviewers. Primary outcomes were recurrence rates and survival rates. There were no secondary outcomes. Data was synthesized using a random effects model and results presented as relative risk with 95% Confidence Intervals. RESULT: For recurrence of hepatocellular cancer after hepatic resection or local ablative therapy, compared with controls, participants receiving Vitamin K2, pooled relative risks for hepatocellular cancer were 0.60; 95% CI: 0.28-1.28, p = 0.64) at 1 yr 0.66; 95% CI: 0.47-0.91), p = 0.01) at 2 yr; 0.71; 95% CI: 0.58-0.85, p = 0.004) at 3 yr respectively. The results were combined using the random analysis model. CONCLUSION: Five RCTs evaluated the preventive efficacy of menatetrenone on HCC recurrence after hepatic resection or local ablative therapy. The meta-analysis of all five studies, failed to confirm significantly better tumor recurrence- free survival at 1 year. Improved tumor recurrence at 2nd and 3rd year may be just due to insufficient data. There was no beneficial effect on the overall survival. However, to confirm the beneficial effect or lack of it, large, higher quality randomized controlled trials are still required.

Prevalence of hepatitis 'B' and hepatitis 'C' among preoperative cataract patients in Karachi.

BACKGROUND: To report the findings of preoperative screening regarding prevalence of hepatitis B and hepatitis C in patients presenting for cataract surgery. FINDINGS: A descriptive study was conducted among 377 patients presenting for cataract surgery to Department of Ophthalmology Unit I, CHK from April 2010 to May 2011. Convenience sampling was done to recruit the participants aged 18 years and above. The patients were screened for hepatitis B and C infections and findings were recorded on a structured compilation sheet.The total prevalence of both hepatitis B and hepatitis C in preoperative Cataract patients was found to be 49 out of 377(12.99%). Overall, 8 out of 377 (2.1%) patients were HBsAg positive and 42 out of 377 (11.1%) were Anti-HCV positive. Only 1 patient was found with a co-infection with both HBsAg and Anti-HCV positive. CONCLUSIONS: High proportions of hepatitis B and C are reported among preoperative cataract patients of Karachi. Routine serological screening prior to surgery should be made mandatory so that asymptomatic patients would no longer pose a threat to its spread.

Prevalence and factors associated with irritable bowel syndrome among medical students of Karachi, Pakistan: a cross-sectional study.

BACKGROUND: Irritable bowel syndrome (IBS) and its association with stress, has not been studied among university students in Pakistan. We investigated the prevalence and the pattern of anxiety related IBS symptoms among medical students of Karachi. FINDINGS: An observational case-control study was carried out at three medical colleges of Karachi, Pakistan. Random sampling was done on 360 medical students. Data was collected using validated tools "Rome III Criteria" and "Generalized Anxiety Disorder Questionnaire". Participants with IBS were diagnosed on the criteria having experienced abdominal discomfort at least 2-3 days/month associated with high level of anxiety. The apparent prevalence of IBS was found to be 28.3%, with a predominance of 87 (85.29%) females (85.29%) over males (14.71%). The psychological symptoms of anxiety were encountered in 57 (55.8%) participants with IBS, among which males were 15.7% and females 84.2% respectively. CONCLUSION: Students who more frequently suffer with mental stress and anxiety are more associated with IBS.

Serum ferritin levels, socio-demographic factors and desferrioxamine therapy in multi-transfused thalassemia major patients at a government tertiary care hospital of Karachi, Pakistan.

BACKGROUND: Beta thalassemia is the most frequent genetic disorder of haemoglobin synthesis in Pakistan. Recurrent transfusions lead to iron-overload manifested by increased serum Ferritin levels, for which chelation therapy is required. FINDINGS: The study was conducted in the Pediatric Emergency unit of Civil Hospital Karachi after ethical approval by the Institutional Review Board of Dow University of Health Sciences. Seventy nine cases of beta thalassemia major were included after a written consent. The care takers were interviewed for the socio-demographic variables and the use of Desferrioxamine therapy, after which a blood sample was drawn to assess the serum Ferritin level. SPSS 15.0 was employed for data entry and analysis.Of the seventy-nine patients included in the study, 46 (58.2%) were males while 33 (41.8%) were females. The mean age was 10.8 (± 4.5) years with the dominant age group (46.2%) being 10 to 14 years. In 62 (78.8%) cases, the care taker education was below the tenth grade. The mean serum Ferritin level in our study were 4236.5 ng/ml and showed a directly proportional relationship with age. Desferrioxamine was used by patients in 46 (58.2%) cases with monthly house hold income significant factor to the use of therapy. CONCLUSIONS: The mean serum Ferritin levels are approximately ten times higher than the normal recommended levels for normal individuals, with two-fifths of the patients not receiving iron chelation therapy at all. Use of iron chelation therapy and titrating the dose according to the need can significantly lower the iron load reducing the risk of iron-overload related complications leading to a better quality of life and improving survival in Pakistani beta thalassemia major patients.Conflicts of Interest: None.